[Senate Hearing 117-280]
[From the U.S. Government Publishing Office]


                                                       S. Hrg. 117-280

                     A NATIONAL TRAGEDY: COVID-19 
                     IN THE NATION'S NURSING HOMES

=======================================================================

                                HEARING

                               BEFORE THE

                          COMMITTEE ON FINANCE
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 17, 2021

                               __________


[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                                     
                                     

            Printed for the use of the Committee on Finance

                                __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
47-758 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------   

                          COMMITTEE ON FINANCE

                      RON WYDEN, Oregon, Chairman

DEBBIE STABENOW, Michigan            MIKE CRAPO, Idaho
MARIA CANTWELL, Washington           CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey          JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware           JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland         RICHARD BURR, North Carolina
SHERROD BROWN, Ohio                  ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado          PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania   TIM SCOTT, South Carolina
MARK R. WARNER, Virginia             BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island     JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire         STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada       TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts      BEN SASSE, Nebraska
                                     JOHN BARRASSO, Wyoming

                    Joshua Sheinkman, Staff Director

                Gregg Richard, Republican Staff Director

                                  (ii)
                            
                            C O N T E N T S

                              ----------                              

                           OPENING STATEMENTS

                                                                   Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee 
  on Finance.....................................................     1
Crapo, Hon. Mike, a U.S. Senator from Idaho......................     3

                               WITNESSES

Ramos, Adelina, Certified Nursing Assistant, SEIU District 1199 
  New England, Greenville, RI....................................     6
Bottcher, Denise, State director, AARP Louisiana, Baton Rouge, LA     7
Moten, Quiteka, MPH, CDP, State Long-Term Care Ombudsman, 
  Commission on Aging and Disability, State of Tennessee, 
  Nashville, TN..................................................     9
Konetzka, R. Tamara, Ph.D., Louis Block professor, Department of 
  Public Health Sciences, Biological Sciences Division, 
  University of Chicago, Chicago, IL.............................    11
Dicken, John E., Director, Health Care, Government Accountability 
  Office, Washington, DC.........................................    13
Gifford, David, M.D., MPH, chief medical officer, American Health 
  Care Association/National Center for Assisted Living, 
  Washington, DC.................................................    14

               ALPHABETICAL LISTING AND APPENDIX MATERIAL

Bottcher, Denise:
    Testimony....................................................     7
    Prepared statement...........................................    53
    Responses to questions from committee members................    56
Brown, Hon. Sherrod:
    Submissions for the record...................................    61
Crapo, Hon. Mike:
    Opening statement............................................     3
    Prepared statement...........................................   132
Dicken, John E.:
    Testimony....................................................    13
    Prepared statement...........................................   133
    Responses to questions from committee members................   143
Gifford, David, M.D., MPH:
    Testimony....................................................    14
    Prepared statement...........................................   155
    Responses to questions from committee members................   163
Konetzka, R. Tamara, Ph.D.:
    Testimony....................................................    11
    Prepared statement...........................................   175
    Responses to questions from committee members................   180
Moten, Quiteka, MPH, CDP:
    Testimony....................................................     9
    Prepared statement...........................................   188
    Responses to questions from committee members................   190
Ramos, Adelina:
    Testimony....................................................     6
    Prepared statement...........................................   193
    Responses to questions from committee members................   195
Scott, Hon. Tim:
    Prepared statement...........................................   197
Wyden, Hon. Ron:
    Opening statement............................................     1
    Prepared statement...........................................   198

                             Communications

Alzheimer's Association and Alzheimer's Impact Movement..........   201
American Geriatrics Society......................................   203
Arbeeny, Dan.....................................................   206
Carter, Marla....................................................   209
Caspi, Eilon, Ph.D...............................................   214
Center for Fiscal Equity.........................................   215
Center for Medicare Advocacy.....................................   218
Hamilton, Elizabeth..............................................   224
Holland, Tamra...................................................   225
Hull, Gay L......................................................   227
James, Kathy.....................................................   227
Justice in Aging.................................................   228
Landry, Lydia Nunez..............................................   231
LeadingAge.......................................................   236
Leljedal, Carrie.................................................   240
Mimbs, Ja'Nisa...................................................   242
National Consumer Voice for Quality Long-Term Care et al.........   243
Nichols, Mary....................................................   252
Oregon Health and Science University.............................   254
Piper, Carolyn...................................................   255
Premier Inc......................................................   258
Rister, Beth.....................................................   262
Toscano, Nora....................................................   263
Wasserman, Michael R., M.D., CMD.................................   266
Winters, Rachel..................................................   273

 
                     A NATIONAL TRAGEDY: COVID-19 
                     IN THE NATION'S NURSING HOMES

                              ----------                              


                       WEDNESDAY, MARCH 17, 2021

                                       U.S. Senate,
                                      Committee on Finance,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10 a.m., 
via Webex, in the Dirksen Senate Office Building, Hon. Ron 
Wyden (chairman of the committee) presiding.
    Present: Senators Stabenow, Cantwell, Menendez, Cardin, 
Brown, Bennet, Casey, Warner, Whitehouse, Hassan, Cortez Masto, 
Crapo, Grassley, Thune, Portman, Toomey, Cassidy, Lankford, 
Daines, Young, and Barrasso.
    Also present: Democratic staff: Peter Gartrell, 
Investigator; Kristen Lunde, Health Policy Advisor; and Joshua 
Sheinkman, Staff Director. Republican staff: Gregg Richard, 
Staff Director; Erin Dempsey, Deputy Health Policy Director; 
and Stuart Portman, Senior Health Policy Advisor.

   OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM 
             OREGON, CHAIRMAN, COMMITTEE ON FINANCE

    The Chairman. This morning, the Finance Committee is 
holding the second of three hearings that we will be holding 
this week. And this is a particularly important hearing, 
because our country is now a full year into the COVID-19 
pandemic.
    And let me just give a brief kind of process statement with 
respect to how we are going to do this. We have two votes at 
11:30, and we are going to do everything we can to keep this 
moving. We have been working with the ranking member, Senator 
Crapo, on this. And if we do not do that, we will probably be 
here until 3 o'clock. So we are going to do our best to keep 
this moving.
    As I indicated, we are a year in, and vaccinations are up. 
Americans are beginning to feel encouraged, and yet so many 
families--hundreds of thousands spread across the country--are 
unable to share in the sense of uplift because they are 
mourning loved ones whom they have lost.
    Over the last year, more than 175,000 long-term care 
residents and workers, including 130,000 living and working in 
federally certified nursing homes, have died of this terrible 
disease. They were at the center of a collision of 
mismanagement. In too many nursing homes--even before the 
pandemic--there was chronic under-
staffing, slipshod plans for infection control, and abuse and 
neglect of vulnerable patients.
    When COVID-19 arrived, the Trump administration came up 
small by withholding data, failing to distribute protective 
equipment, and issuing guidance that put seniors in harm's way. 
This was a systemic, nationwide failure, and it will be 
challenging to fix. Members can start by agreeing on basic 
facts.
    First, what is true of the overall population is true in 
our nursing homes. Blacks, Latinos, and Native Americans are 
suffering the worst of COVID-19. A recent study authored by 
Professor Konetzka, one of the witnesses joining the committee, 
found that the loss of life was more than three times higher in 
nursing homes with the highest proportions of black and Latino 
residents compared to facilities with mostly white residents.
    Black Americans and immigrants also make up a 
disproportionate share of nursing home staff. Often, they get 
paid low wages. More than half a million of them have had 
confirmed cases of COVID-19, and thousands have died. There is 
also real concern that COVID-19 will continue to circulate 
among those communities where vaccines are not readily 
available, or where uptake is lower.
    These disparities in COVID-19 deaths are the result of 
generations of inequity in society and in health care. Undoing 
it is going to take a lot of work by this committee, and I know 
colleagues feel very strongly about getting it done.
    Second, the previous administration actively impeded 
efforts to address long-running problems in nursing homes. You 
could fill a library with the watchdog reports calling public 
attention to these issues: incidents of abuse and neglect, 
chronic under-staffing, horrendous living conditions, 
inadequate emergency preparedness. This was an industry-wide 
failure also when it came to inspection control.
    Instead of addressing these questions, the Trump 
administration dramatically reduced the penalties for failing 
to meet basic protective Federal standards. They went out of 
their way to undermine a chance for real accountability. When 
States rushed to develop COVID policies, some followed Trump 
administration guidance that encouraged nursing homes to accept 
patients regardless of whether they had tested positive for the 
virus.
    When the pandemic was spreading and nursing homes 
desperately needed PPE, the Trump administration sent out 
shipments that reportedly included loose, unusable gloves, 
hospital gowns that resembled trash bags, and defective masks.
    The Trump administration did not want people to know about 
what was going on in nursing homes. Our colleague, Senator 
Casey, and I spent months pressuring and pleading with them to 
release comprehensive data. The Trump administration 
stonewalled. They dithered, and they delayed before they 
finally began to relent. As of now, there still is no reliable 
data on COVID in nursing homes before May 1st of last year 
because of the Trump administration's stonewalling.
    One final point. The terrible impact of COVID-19 on seniors 
in long-term care is not a red State or a blue State issue. It 
is a nationwide tragedy. Specifically, if you look at the 10 
States where nursing homes have been hit the hardest, it is 
five Republican-led States and five Democratic-led States.
    So the reality is, long-term care residents in all 50 
States are incredibly vulnerable to a pandemic like COVID-19 
for longstanding reasons, but the Trump administration worked 
harder to protect their unscrupulous friends in management than 
to improve the safety of residents.
    The Biden administration is working to turn things around. 
It starts with ramping up vaccinations and creating strike 
teams of highly trained workers who will go into nursing homes 
and identify the safety risks.
    This hearing is not the first or the last time the 
committee is going to be digging into nursing home safety. We 
are going to continue to work with members, all members of this 
committee, because looking after the well-being of America's 
seniors is at the heart of our jurisdiction.
    Personally, I feel strongly about this after my 7 years as 
co-
director of the Oregon Gray Panthers, and I look forward to 
working with colleagues on both sides of the aisle.
    We will start with our panelists, and an introduction, 
right after Senator Crapo's opening statement.
    [The prepared statement of Chairman Wyden appears in the 
appendix.]

             OPENING STATEMENT OF HON. MIKE CRAPO, 
                   A U.S. SENATOR FROM IDAHO

    Senator Crapo. Thank you, Mr. Chairman.
    At the national, State, and local levels the pandemic has 
challenged our sense of normalcy. It has tested every 
institution of daily life we know, threatening the physical and 
economic health of our Nation.
    Americans from all walks of life have experienced a full 
year of tremendous hardship and tragedy. It is the people 
living and working in our Nation's nursing homes, however, who 
bore an outsized burden.
    More than 174,000 people died as COVID-19 ravaged our long-
term care facilities. That number represents almost one-third 
of all U.S. deaths that have occurred during the pandemic.
    Both long-stay nursing homes and short-stay post-acute 
skilled nursing facilities rely on direct-care workers--such as 
licensed practical nurses, Certified Nursing Assistants, and 
personal care aides--to provide most hands-on care.
    These workers are in close physical contact with residents, 
assisting with bathing, dressing, and eating. Current data 
shows that long-term care workers are typically female, and a 
disproportionate share are women of color. Many of these 
direct-care workers live paycheck to paycheck. Over the past 
year, they have put their lives on the line. We owe them a debt 
of gratitude. Thank you to the dedicated nursing home workers 
like Adelina Ramos, one of our witnesses.
    These workers hear Americans calling them heroes, but they 
are often under-appreciated when on the job. To these front-
line workers, please know that the sacrifices you are making 
every day do not go unnoticed or unappreciated.
    Today we will hear from a number of expert witnesses who 
will provide key insights into nursing home conditions over the 
past year. This testimony will help us better understand 
exactly what happened, when it happened, and why it happened. 
It will give us insight into policies that produce results, as 
well as areas that need improvement.
    Hearings are just oversight tools this committee uses to 
hold government agencies, the health-care industry, and 
individual providers accountable. Another key part of oversight 
is securing reliable and accurate data.
    Transparent data reporting brings accountability and helps 
drive decision-making. Transparent data reporting brings 
tremendous support to the system. As we look to the future, it 
is vital that all States report accurate COVID-19 data. That is 
the only way for economists, researchers, advocacy 
organizations, and policy-makers to tackle the challenges 
facing the nursing home sector head-on.
    This is not a job for the Federal Government alone. 
Multiple Federal, State, and local programs and partnerships 
work to support the health-care needs of our Nation's most 
vulnerable populations. We must work together--in an honest and 
transparent manner--to safeguard our nursing home residents and 
the workers who care for them.
    Over the weekend, The New York Times published the results 
of an investigation into the Centers for Medicare and Medicaid 
Services' nursing home five-star rating system. The 
investigation questions the objectivity and accuracy of the CMS 
star ratings system.
    This rating system, which was first implemented during the 
Obama administration, is designed to help beneficiaries, their 
families, and caregivers compare nursing home quality more 
easily.
    Care Compare is another online tool available to help 
seniors, the disabled, and their families find out if a 
particular nursing home facility meets Federal health and 
safety standards, staffing levels, and quality performance 
metrics.
    After several bipartisan hearings held by the Finance 
Committee during 2019, CMS implemented changes to Nursing Home 
Compare that specifically denote nursing homes that have been 
cited for incidents of abuse, neglect, or exploitation.
    That may have been a start, but clearly there is a lot more 
work that needs to be done. I am grateful to each of our 
witnesses for the work they are doing, and for taking the time 
to join us today. Their expertise will help us advance public 
policies that slow the spread of COVID-19 and lessen its 
devastating impacts on our Nation's elderly and the disabled.
    And, Mr. Chairman, before I conclude, Senator Scott will 
not be able to make his statement, or be participating today, 
but he is one of the leaders in our Senate on trying to deal 
with and address this issue properly. And he has asked that I 
request a statement of his be entered into the record.
    I ask unanimous consent that his statement be entered into 
the record.
    The Chairman. Without objection, so ordered.
    [The prepared statement of Senator Scott appears in the 
appendix.]
    Senator Crapo. Thank you very much, Mr. Chairman.
    [The prepared statement of Senator Crapo appears in the 
appendix.]
    The Chairman. Okay. We are now going to go to our panel. 
Senator Whitehouse has requested to introduce Ms. Ramos. We are 
very glad that you could be here and have known of your efforts 
for quite some time, Ms. Ramos. So we are glad you are here.
    Senator Whitehouse?
    Senator Whitehouse. Thank you, Mr. Chairman.
    Rhode Island lost more than 1,000 nursing home residents to 
COVID. Nationwide, as Senator Crapo pointed out, there have 
been more than 174,000 nursing home residents and caretakers 
who have died.
    Nearly a quarter of Rhode Island's nursing homes reported 
shortages of nurses and nursing aides during the pandemic. So I 
am very pleased and grateful that the committee will be hearing 
from Rhode Islander Adelina Ramos today.
    She lived this crisis as a Certified Nursing Assistant at 
the Greenville Nursing Center in Greenville, RI. She is a proud 
SEIU member, and I am grateful to her and to her union.
    From late April to Memorial Day, Ms. Ramos witnessed 20 
residents at her 160-bed facility perish. She watched a 
colleague die. In one harrowing moment, she and a team of just 
three staffers cared for over two dozen critically ill COVID 
patients.
    Eventually, she caught the virus herself, and feared 
spreading it to her family, for whom she also provides care at 
home. At last, Ms. Ramos is fully vaccinated and hopeful for 
the future.
    Senator Casey and I worked to provide our nursing homes 
emergency funding for staffing and testing and PPE, and for 
nursing home strike teams to boost capacity at facilities in 
need. We finally got much of this support into the American 
Rescue Plan, but it had been blocked in all the previous COVID 
bills.
    It would have served Adelina and her colleagues better if 
we had done this earlier, but at least we got it done at last.
    So I am pleased to welcome Ms. Ramos here to our committee. 
Thank you, Mr. Chairman, and thank you, Ranking Member.
    The Chairman. Thank you very much, Senator Whitehouse. At 
this point, I am just going to give brief introductions for our 
other guests.
    Denise Bottcher is here. She is a State director of AARP in 
Louisiana. She has worked for AARP since 2010, and previously 
was with Governor Kathleen Blanco.
    Then we will have a very important presentation from a 
Long-Term Care Ombudsman, Quiteka Moten. She is from Tennessee. 
She is based in Nashville. She works with the Alzheimer's 
Association now, establishing rural senior networks, training 
first responders, and managing early-stage engagement programs.
    And then Tamara Konetzka, Louis Block professor of public 
health in the Department of Public Health Sciences at the 
University of Chicago. She serves on a number of Federal 
boards. She received her Ph.D. from the University of North 
Carolina. We are very glad to have her because we have seen her 
renowned scholarship, and we look forward to her presentation.
    So, let's begin with Ms. Ramos.

 STATEMENT OF ADELINA RAMOS, CERTIFIED NURSING ASSISTANT, SEIU 
           DISTRICT 1199 NEW ENGLAND, GREENVILLE, RI

    Ms. Ramos. Thank you, Mr. Chairman, Ranking Member Crapo, 
and the members of the Senate community. My name is Adelina 
Ramos. I am a CNA at a nursing home in Greenville, RI. I am a 
proud immigrant from the Cape Verde Islands off the western 
coast of Africa.
    At my facility, I work with Alzheimer's patients. To be 
trusted by families to care for their loved ones is a great 
honor. But over the past year, my days have been filled with 
fear and sadness.
    I do not think anyone in my small community thought that 
COVID-19 would arrive at our doorstep. But it did, and nursing 
homes were not prepared. When COVID first hit, we lost over 20 
residents in just over a month--and a CNA died too.
    We confronted management to let them know we did not have 
enough PPE or enough training to keep our residents safe and to 
prevent the virus from spreading in our facility.
    We are extremely short-staffed too. At one point, I was 
caring for 26 critically ill residents with the help of only 
one other CNA, a nurse, and a housekeeper. They could not eat, 
drink, or move by themselves. Some of them required oxygen 
changes every 15 minutes. And because they had Alzheimer's, 
sometimes they would get scared.
    I was horrified. We begged management for more staff on 
each shift, but they said they could not find anyone. And so 
our residents and staff kept getting sick and dying.
    The day after Mother's Day, I realized I could not smell my 
ginger tea. I thought it was because of my mask. But a few 
weeks later, I got symptoms and I had COVID. I did not have 
other symptoms, so I did not know, and I put those around me at 
risk. I never thought I would have to tell my son to stay away 
from me, don't touch me, don't hug me, don't get too close. I 
would never be able to forgive myself if I infected him, so I 
did what I had to do to keep him safe.
    Today, I am COVID-free and vaccinated, and I am holding my 
family close. And I am working to educate others about how 
important it is to get vaccinated. Things are looking up, but 
the physical and emotional trauma this pandemic caused cannot 
be cured with a shot in the arm.
    When I started working at a nursing home, I understood I 
would have residents pass away. In their final moments, our job 
is to make sure they are comfortable, cared for, and surrounded 
by loved ones. The family members could not come into our 
facility. The funeral homes could not come either, because they 
did not have enough PPE. So we became the mortician and had to 
put bodies into body bags.
    My residents deserved so much better than what we were able 
to provide them, with few staff and resources. As they took 
their final, difficult breath, I hope they knew that we tried 
our best.
    The starting wage for Rhode Island nursing home workers is 
just $12.34. Some of us have to work multiple jobs to meet our 
basic needs. Because of these actions, we do not have time to 
spend with the residents when they need us.
    My worst day during COVID was when one of my residents was 
dying and wanted me to sit and hold her hand, but I could not 
stay because I had 20-plus other residents who also needed me.
    I feel a calling to do this job and care for others, but 
passion cannot pay bills. I am fortunate that I am a member of 
my union, SEIU 1199 New England. We negotiated higher wages and 
pandemic pay. We were able to advocate for ourselves and 
residents, but not every nursing home worker has a union.
    This issue existed before COVID. COVID-19 just exposed the 
most tragic and deadly part of nursing home work. It is why I 
keep fighting for a $15 minimum wage in the union for all 
workers.
    This pandemic has shown us what happens when we are not 
prepared to meet the demands for care. We must build back 
better so that when the time comes when your loved one needs 
care--and that time will come for all of us--someone like me 
will be there to answer your call.
    [The prepared statement of Ms. Ramos appears in the 
appendix.]
    The Chairman. Ms. Ramos, thank you. And we wanted you to 
speak first because we felt that you could really give us a 
sense of what this was like on the floor where patients lived, 
and the challenge. And we knew you were going to give us an 
important presentation. And thank you, thank you, thank you, 
because you are speaking for so many this morning.
    Our next speaker will be Denise Bottcher, and, let's see, 
there is Ms. Bottcher. Please proceed.

         STATEMENT OF DENISE BOTTCHER, STATE DIRECTOR, 
                AARP LOUISIANA, BATON ROUGE, LA

    Ms. Bottcher. Good morning, Chairman Wyden, Ranking Member 
Crapo, and members of the committee. My name is Denise 
Bottcher, and I am State director for AARP of Louisiana. On 
behalf of our 38 million members--including over 425,000 in 
Louisiana--and all older Americans nationwide, AARP appreciates 
the opportunity to provide testimony at today's hearing.
    The situation in our Nation's nursing homes and other long-
term care facilities has been alarming since the first COVID 
outbreak in Washington State. AARP has heard from thousands of 
people who have lost loved ones, and that is why, across the 
Nation, AARP has advocated for the health, safety, and well-
being of residents and staff.
    As has been mentioned, over 175,000 long-term care facility 
residents and staff have died. And that includes almost 3,000 
in Louisiana. This represents about 35 percent of deaths 
nationwide. While there may be a sense of relief with vaccines 
rolling out and infection rates declining, much more is needed 
to protect nursing home residents.
    The consequence of not acting is that someone's mother or 
father dies. One resounding message I have received from 
families across Louisiana is this: if 175,000 deaths does not 
inspire bold action, then nothing will.
    AARP has urged action in a five-point plan to protect the 
health and safety of residents.
    First, ensure facilities have adequate personal protective 
equipment for everyone at the facility, and ensure its 
consistent and proper use, as well as prioritizing testing.
    Yesterday I had the opportunity to visit with Mark Ferguson 
in Lake Charles, LA. His 86-year-old dad and 63-year-old 
brother lived in the same nursing home. And every week he 
visited with his dad and brother through a window. And each 
time, he observed staff not wearing masks or gloves.
    He told me he felt helpless in this moment because it was a 
matter of life and death. The only thing he could do was call 
and report it to the administrator. The following week, he 
would again visit, and the staff were not properly wearing PPE. 
He eventually lost his dad to COVID, and he still fights this 
battle today.
    I asked him what keeps him up at night, and he told me the 
health and safety of his brother Scott. It is unacceptable for 
facilities to have PPE shortages a year into the pandemic.
    AARP's second point: continue to improve transparency. We 
believe care facilities should publicly report cases and deaths 
daily, rather than weekly. That reporting should include 
demographic data such as race and ethnicity.
    Information about the number and percentage of residents 
and staff who have been vaccinated should be available by 
facility and State. We urge the Federal Government to work with 
States and long-term care facilities to ensure they can access 
and administer vaccines to new residents and staff as needed.
    Finally, millions of taxpayer dollars from the Provider 
Relief Fund have gone to facilities to fight COVID. AARP 
strongly urges that the administration and Congress ensure that 
these funds are directly used for the health, safety, and care 
of residents and staff.
    AARP's third point is to ensure safe access to in-person 
visitation, following Federal and State guidelines, and to 
require continued access to facilitated virtual visitation for 
all residents.
    Our fourth point is to ensure quality care for residents 
through adequate staffing and oversight. We are deeply 
concerned about staffing shortages at facilities--and even 
before the pandemic. According to AARP's Nursing Home 
Dashboard, over 25 percent of nursing homes across the Nation 
have reported a staffing shortage since June of 2020. 
Residents' health and safety are at continued risk without 
adequate staffing.
    Finally, oversight and enforcement are a shared 
responsibility between Federal and State agencies. Oversight 
from CMS and State survey agencies, including regular annual 
surveys, is vital now more than ever.
    AARP 's final point is to reject immunity and hold long-
term care facilities accountable when they fail to provide 
adequate care to residents.
    You know, when I speak to folks, young and old, about how 
they want to live their lives, an overwhelming majority tell me 
they want to live at home for as long as possible with the 
support of family and friends. Helping people to remain in 
their homes and communities would help alleviate some of the 
challenges we are facing in our Nation's nursing homes. This 
includes supporting family caregivers who make it possible.
    Families across the country are looking to Congress and the 
administration for swift action to protect the health and 
safety of their loved ones living in long-term care facilities 
now, and well into the future. We cannot wait any longer.
    Thank you.
    [The prepared statement of Ms. Bottcher appears in the 
appendix.]
    The Chairman. Thank you.
    Let's go next to Ms. Moten, the Ombudsman. Ms. Moten, 
welcome.

  STATEMENT OF QUITEKA MOTEN, MPH, CDP, STATE LONG-TERM CARE 
    OMBUDSMAN, COMMISSION ON AGING AND DISABILITY, STATE OF 
                    TENNESSEE, NASHVILLE, TN

    Ms. Moten. Thank you. Good morning.
    Thank you, Chairman Wyden, Ranking Member Crapo, and 
distinguished members of the committee. I am Teka Moten, State 
Long-Term Care Ombudsman for Tennessee.
    I am honored to discuss my experiences, challenges, and 
lessons learned while serving residents during COVID. I want to 
first thank you for CARES funding and American Recovery Act 
funding. It has greatly assisted in the provision of programs 
and activities, as well as the procurement of equipment and PPE 
in this time.
    I sit before you as a Certified Dementia Practitioner, 
trainer, and coach, as well as a former volunteer Ombudsman. I 
have spent the entirety of my career in public service--
specifically, Asian programs and policies.
    I began as State Ombudsman of Tennessee January 17, 2020. I 
had less than 60 days to learn my role, staff, and major 
stakeholders prior to the lockdown. Coincidentally enough, 
there was also a tornado that affected the Nashville area and 
the upper Cumberland region, and this affected a number of 
long-term care homes.
    Swedish for the term ``representative of the people,'' the 
Ombudsman Program is an essential component to the oversight of 
long-term care facilities. We operate as a community-based at-
the-
bedside advocacy program for the rights of residents.
    We handle complaint investigations as laid out by the CMP 
State Operations Manual. The major components of the Ombudsman 
Program, fortified by the Older Americans Act, include a 
mandated quarterly visit to our nursing homes by staff 
Ombudsmen, and regular visits to communities by trained and 
designated volunteer Ombudsmen who, at the average age of 70, 
are very much a vital and integral part of our program.
    COVID, alongside ensuing policies, disrupted the Ombudsman 
Program's immediate access to residents. The inability to have 
face-to-face meetings made it difficult to verify complaints, 
assure confidentiality, and to readily gain consent for the 
medical surrogates or POAs.
    In addition, it made it difficult for us to advocate on 
behalf of residents being discharged against their wishes, 
oftentimes leaving them in behavioral health or medical centers 
with the risk of losing their Medicaid. Particularly affected 
by these major barriers are people living with dementia, those 
who are aphasic or unable to speak, those who are deaf or hard 
of hearing but have assisted technology needs, those without 
the manual dexterity to pick up the phone, and those with that 
ability who were without a phone or had to purchase their own.
    Residents in fact were not silent. Lack of staffing and 
inability to be with their families silenced them. But staffing 
issues were nothing new in the most-regulated industry in this 
country.
    Nursing homes were already dealing with a workforce 
shortage, and COVID exacerbated that issue further. Staff 
members got sick, as you have already heard. Many had to 
quarantine, and some faced a lack of child care options.
    What resulted was an overall decline in the quality of care 
that our residents received. Throughout the country, Ombudsmen 
received complaints of dehydration, unanswered call lights, a 
lack of basic care and assistance--cleaning, bathing, feeding--
but most identifiable probably, a lack of repositioning, which 
left residents in the bed, resulting in an exponential increase 
in bed sores.
    Unchanged catheters and pressure sores resulted in sepsis, 
and sometimes death, for our residents. There are issues of 
dignity and hygiene stemming from residents having to sit in 
their own feces and urine for hours on end, delayed discharges 
to hospistals for serious conditions, access and transport 
issues to dialysis and other appointments, and an uptake in 
facility-initiated hospice.
    Residents dealing with COVID, its reoccurrence, testing, 
and room changes had to deal with resident isolation. This led 
to emotional distress and physical decline.
    I can remember, vividly, calls from skilled rehab residents 
who would recount their experience in facilities. For me, the 
toughest part was knowing that if we received calls to our 
hotline on the weekend and the evenings, it was more than 
likely it was a resident who knew that there were going to be 
less staff in the building.
    Worried family members also shared their concerns for 
unkempt residents as they looked on in discontentment at 
disheveled hair, unbrushed teeth, and filthy fingernails. This 
added to our task of helping family caregivers adapt to a 
different type of caregiver's role, especially for those moving 
into a facility in the midst of COVID.
    But for those who would take their final breaths in nursing 
homes, the term ``compassionate care'' altogether presented 
another set of challenges for us in dealing with the discretion 
of facilities.
    Ombudsmen have worked tirelessly throughout the last year. 
Ideally, the worst has subsided, yet the fact remains that 
residents of long-term care make up less than 1 percent of the 
U.S. population, but as of March 4, 2021, they account for 34 
percent of all deaths in America.
    As we move forward, it is my hope that we can lean on a few 
actionable items: for facilities, a comprehensive plan for 
recruiting and retaining staff; for the Ombudsman Program, 
consideration as an essential part of a system that responds to 
and supports the safety and welfare of residents, regardless of 
any status the State may bestow upon them; and last but not 
least, for the residents remaining in our facilities, the 
loving embrace of family, friends, pets, and a return to some 
version of normalcy.
    [The prepared statement of Ms. Moten appears in the 
appendix.]
    The Chairman. Thank you, very much.
    Our final two witnesses will be John Dicken, Director of 
Health Care at the Government Accountability Office, where he 
has worked since 1991. He oversees a portfolio of audits on 
health-care questions, and he has been before us before, and we 
appreciate it.
    And then we will close with Dr. David Gifford, an M.D. and 
a master of public health, chief medical officer of the 
American Health Care Association and a geriatrician.
    But first, let us proceed now to Dr. Konetzka.

STATEMENT OF R. TAMARA KONETZKA, Ph.D., LOUIS BLOCK PROFESSOR, 
   DEPARTMENT OF PUBLIC HEALTH SCIENCES, BIOLOGICAL SCIENCES 
          DIVISION, UNIVERSITY OF CHICAGO, CHICAGO, IL

    Dr. Konetzka. Chairman Wyden, Ranking Member Crapo, and 
distinguished members of the committee, thank you for holding 
this hearing.
    My name is Tamara Konetzka. I am a professor of health 
economics at the University of Chicago, and I have been 
conducting research on long-term and post-acute care for more 
than 25 years. I have intensely studied COVID-19 in nursing 
homes during this pandemic. I will focus my remarks on what we 
have learned from research, followed by recommendations.
    First, what do we know about the predictors of nursing home 
cases and deaths? A large body of evidence shows that the two 
strongest and most consistent predictors of worst COVID-19 
outcomes are larger nursing home size and COVID-19 prevalence 
in the surrounding community.
    Given two similar nursing homes with an outbreak, being in 
a virus hotspot is associated with five more deaths. Equally 
important are nursing home attributes that are not linked with 
COVID-19 outcomes.
    Multiple rigorous studies have found no meaningful 
association between COVID-19 outcomes and standard quality 
metrics. Even prior infection control citations were not 
associated with COVID-19 outcomes. These results suggest that 
high quality and good infection control are not enough in this 
pandemic.
    The numbers bear this out. At this point, more than 99 
percent of nursing homes in the Nation have had at least one 
COVID-19 case. And more than 80 percent have had at least one 
death. This is clearly not a bad apples problem, and no subset 
of nursing homes has found a magic bullet to keep the virus 
out.
    The single most important thing we could have done as a 
Nation to reduce the tragedy in nursing homes over the past 
year was to use public health measures to control the spread of 
the virus in the general population.
    Second, what about disparities? As Chairman Wyden 
mentioned, our research found striking disparities by race. 
Nursing homes serving more residents of color experienced more 
than three times as many COVID-19 cases and deaths as those 
serving primarily white residents.
    Why? Most of the disparity can be explained by what race is 
correlated with. Residents of color are more likely to live in 
larger facilities in neighborhoods where COVID-19 is prevalent.
    Third, are there any predictors of bad outcomes that are 
more amenable to change? In the often-contentious world of 
nursing home policy, it is difficult to find things that 
everyone agrees on, but here is one. On average, nursing homes 
lack sufficient numbers of staff to provide the quality of care 
we would all like to receive.
    In our research, we found that having more staff did not 
reduce the probability of a COVID-19 outbreak, but nursing 
homes with the most staff hours experienced fewer deaths and 
cases once an outbreak occurred.
    The effects of staffing are still dwarfed by the effect of 
community spread. But increasing staffing represents a clear 
intervention that could improve care and save lives during this 
pandemic and beyond.
    This evidence base suggests several policy recommendations 
moving forward.
    First, policies implemented during the past year that 
reward or fine facilities based on COVID deaths are not 
appropriate in a crisis. Instead, I strongly support the 
allocation of American Rescue Plan funds to provide strike 
teams to rapidly fill staffing gaps during an outbreak.
    Second, we must provide greater assistance to large 
facilities in communities of color. Such facilities do not 
typically earn performance bonuses, but may be most in need of 
resources.
    Third, the American Rescue Plan put substantial funding 
into improving infection control. Although improvement is 
certainly necessary, we should recognize that this is a 
solution to a relatively narrow set of problems, a solution 
that would not have avoided the tragedy of the past year.
    Fourth, CMS should immediately release facility-specific 
data on vaccination dates and rates and demographics, including 
race and ethnicities, essential for both research and policy. 
Consumers who are considering nursing home care also have a 
right to know what percent of residents and staff have been 
vaccinated.
    Finally, direct-care staffing in nursing homes needs to be 
increased. Addressing this challenge requires resources, which 
is where the agreement about staffing ends and the harder 
problems begin.
    Many argue--and I largely agree--that America's long-term 
care system is grossly under-funded. At the same time, the 
growing role of related-party transactions and private-equity 
ownership makes it difficult to see where taxpayer money is 
being spent, and what profit margins truly are. Greater 
transparency about the flow of money is urgently needed.
    We will never achieve adequate nursing home quality unless 
we find a way to support the workforce. In addition to low pay 
and few benefits, the job of direct-care nursing staff is 
difficult, often dangerous, and emotionally and physically 
taxing. Add the risk of a potentially fatal infectious disease, 
and it is amazing they show up. Addressing this challenge is 
the best way to honor the memory of the more than 1,900 nursing 
home workers and all the residents who have died from COVID 
thus far. We cannot turn back the clock to prevent the tragedy 
of the past year. We can at least take steps to learn from it.
    Thank you.
    [The prepared statement of Dr. Konetzka appears in the 
appendix.]
    The Chairman. Thank you very much.
    Our next speaker will be John Dicken.

STATEMENT OF JOHN E. DICKEN, DIRECTOR, HEALTH CARE, GOVERNMENT 
             ACCOUNTABILITY OFFICE, WASHINGTON, DC

    Mr. Dicken. Well, good morning, Chairman Wyden, Ranking 
Member Crapo, and members of the committee. Thank you for the 
opportunity to discuss with you findings and recommendations on 
the Federal response to COVID-19 in nursing homes.
    As characterized in the title of today's hearing, and as we 
have heard this morning, the last year has indeed been a 
national tragedy for nursing home residents and their loved 
ones. Just over a year ago, a Washington State nursing home was 
battling one of the first major outbreaks of COVID in the 
United States.
    Today, the pandemic has reached nearly all nursing homes in 
the country. More than 130,000 nursing home residents have died 
from COVID-19, representing nearly 30 percent of all COVID-19 
deaths recorded by the CDC as of early February.
    Even for those nursing home residents not infected, nearly 
all have faced increased isolation and restrictions from loved 
ones. The pandemic has also posed tremendous challenges to the 
homes and their staffs. Notably, more than half a million 
nursing home staff themselves have contracted COVID-19.
    In response to this unprecedented national emergency, HHS 
has taken a series of actions. These include providing guidance 
to States and nursing homes, developing targeted inspections to 
focus on infection control practices, and distributing testing 
devices and vaccines to homes.
    GAO continues to evaluate the Federal response to the 
pandemic in nursing homes as part of a series of comprehensive 
reports to Congress on the government-wide response. My 
statement states a few key findings and recommendations from 
these reviews during the pandemic, as well as our longer-term 
work examining nursing home oversight prior to the pandemic.
    With the ongoing administration of vaccines to nursing home 
residents and staff, nursing homes may be beginning to see a 
reprieve, as cases and deaths declined by more than 80 percent 
as of February from their peaks in December.
    Just last week, CMS updated its guidance to expand resident 
visitations. This issue has posed an ongoing challenge in 
providing residents the ability to have visitors--which can 
benefit their overall mental and physical health--and 
minimizing further COVID-19 outbreaks.
    Other challenges nursing homes have faced in battling 
COVID-19 include obtaining personal protective equipment and 
conducting COVID-19 tests. Although these challenges are still 
notable, they have generally shown signs of improvement.
    Some new challenges have also emerged, such as reluctance 
among some staff to receive a COVID-19 vaccine, and the need 
for continuous vigilance with the emergence of more highly 
transmittable virus variants.
    GAO has made two recommendations specific to HHS's response 
to nursing homes to date. The first recommendation is for HHS 
to develop a strategy for having more complete data on COVID 
cases and deaths in nursing homes, which were only voluntarily 
reported until last May.
    The second recommendation is to more systematically develop 
a plan detailing if and how the Centers for Medicare and 
Medicaid Services will respond to remaining recommendations 
from a commission appointed by former Administrator Verma and 
publicly reported last September.
    To date, CMS has not yet implemented these recommendations. 
We maintain the importance of these recommendations to better 
inform the government's continued response.
    We also made a number of recommendations to improve nursing 
home oversight, as work completed prior to the pandemic, that 
have yet to be implemented. For example, less than 2 years ago 
I testified before this committee regarding GAO's report on the 
abuse occurring in nursing homes. That report made six 
recommendations to CMS, including that CMS require State 
surveyor agencies to immediately notify law enforcement of any 
reasonable suspicion of a crime against a resident.
    These recommendations are particularly relevant during the 
COVID-19 pandemic because, with reduced visitors, Ombudsmen, 
and State surveyor presence, there may be a higher risk of 
abuse going unreported.
    In closing, GAO's recommendations could help address some 
of the challenges nursing homes continue to face, and fill 
important gaps in the Federal Government's understanding of, 
and transparency around, data on COVID-19 in nursing homes.
    Going forward, the spotlight that COVID-19 has placed on 
the vulnerability of nursing home residents may be best used to 
inform future pandemic responses and refocus on longstanding 
challenges that place nursing home residents' health and safety 
at risk.
    This completes my prepared statement.
    [The prepared statement of Mr. Dicken appears in the 
appendix.]
    The Chairman. Thank you very much, Mr. Dicken.
    Dr. Gifford?

 STATEMENT OF DAVID GIFFORD, M.D., MPH, CHIEF MEDICAL OFFICER, 
               AMERICAN HEALTH CARE ASSOCIATION/
      NATIONAL CENTER FOR ASSISTED LIVING, WASHINGTON, DC

    Dr. Gifford. Chairman Wyden, Ranking Member Crapo, and 
distinguished members of the Senate, thank you for making long-
term care providers a priority as you examine how COVID-19 has 
impacted the Nation, and for providing our association the 
opportunity to share our members' challenges during the 
pandemic.
    AHCA represents over 14,000 nursing homes and assisted 
living communities across the country, including not-for-
profit, for-profit, and government facilities. As a 
geriatrician, I can attest that COVID-19 is the greatest 
tragedy ever to impact our residents and their families.
    Over 635,000 residents have been infected, and more than 
130,000 have died, worse than any other infection or disease we 
have faced. This virus has also affected health-care workers, 
with over half a million becoming infected, and thousands 
dying.
    As you know, our residents are at the highest risk for 
COVID-19 complications. More than half are over the age of 85 
and suffer from multiple chronic diseases. Residents depend on 
our nurses, our aides, support staff--including housekeepers--
to help them with their daily activities that require close 
one-on-one contact like eating, getting dressed, and bathing.
    COVID-19 has impacted every aspect of long-term care. For 
nearly a year, family members were unable to visit. Residents 
could not leave their room. They could not see the smiles of 
the nurses and aides caring for them, hidden behind their 
masks.
    Our dedicated staff did everything they could to keep 
residents safe, engaged, and happy. Meanwhile, they constantly 
worried about becoming ill or infecting their family, as Ms. 
Ramos clearly described.
    Our hearts go out to the residents, their families, and the 
health-care workers who have suffered through the past year, 
separated from each other, in some cases forever.
    Why did such devastation happen in long-term care? The 
timeline in my written testimony demonstrates how our knowledge 
of this virus continually evolved, but the public health advice 
could not keep up, and as a result, it was typically too late.
    For example, initial guidance was focused on a symptom-
based approach that we know is ineffective, since half the 
people spreading the virus do not have symptoms. But guidance 
for mask-
wearing for all staff did not come until June, 4 months into 
the pandemic.
    Compounding these challenges was the failure to make 
nursing homes a priority. Despite numerous calls for help, it 
took months to receive much-needed PPE. In many circumstances, 
staff had to use their ingenuity to make their own masks, 
gowns, and face shields.
    I recall getting a call one weekend asking if rain ponchos 
worked better as gowns than trash bags. As we now know, COVID-
19 outbreaks in nursing homes are principally driven by how 
many people in the surrounding community have COVID, as Dr. 
Konetzka testified.
    But testing kits needed to detect asymptomatic carriers of 
the virus were not provided to nursing homes until almost 6 
months into the pandemic. As a result, staff in these 
communities, often unwittingly, brought COVID-19 in the 
building.
    With these delays, even the best nursing homes with the 
most rigorous infection control practices could not stop this 
highly contagious virus. The long-term care community was left 
behind, forgotten, and even blamed. This further demoralized 
the staff, who were risking their lives and trying their best--
with inadequate support.
    It is critical that we determine what we can do to keep 
this from ever happening again. We must reflect on the 
challenges within the long-term care profession that this 
pandemic has exposed and exacerbated.
    We recognize that providers can and must do better to meet 
the needs of the elderly. Prior to COVID-19--and only made 
worse by the pandemic--the long-term care facilities struggled 
to attract and retain a highly dedicated workforce, 
particularly registered nurses, who are most in need during an 
infectious disease outbreak. Our ability to find nurses and 
other caregivers is correlated with the lack of availability 
and proper funding.
    As many academic experts have highlighted, chronic Medicaid 
under-funding makes it a challenge for providers to compete 
with hospitals for nurses and make infrastructure changes.
    What we have learned from this tragedy is that it will take 
considerable investment to make meaningful changes. We stand 
ready to work with policy-makers and others to take bold 
action. Earlier this week, AHCA and LeadingAge together 
announced the Care for Our Seniors Act, a set of proposals 
focused on clinical improvements, strengthening and supporting 
our workforce, improving oversight--particularly for 
chronically poor-performing facilities--and modernizing our 
physical structures.
    The good news is that nursing home residents and staff were 
made a priority to receive the remarkably safe and effective 
COVID-19 vaccine. As a result, cases and deaths have declined 
dramatically since mid-December. Making them a priority for the 
vaccine demonstrates the power of putting long-term care and 
our Nation's seniors first during emergencies.
    On behalf of the staff and the residents in nursing homes 
around the country, I would like to thank the Senate and the 
members of this committee for your dedication and leadership 
during this pandemic.
    We look forward to working with you on implementing 
constructive solutions to combat COVID-19 and usher in a strong 
long-term care system.
    [The prepared statement of Dr. Gifford appears in the 
appendix.]
    The Chairman. Thank you, Dr. Gifford. And all of you have 
been excellent.
    I am going to begin my questioning with you, Ms. Ramos, 
because I was listening to what you said, and it was clear you 
too are at the center of this collision of mismanagement. You 
talked about the under-staffing issue. You talked about the 
problems getting PPE, protective equipment. You mentioned the 
fact that you all were in the dark with respect to getting 
information.
    And I think, apropos of information, I heard you say that 
there was concern among health-care workers--and you, 
initially--about getting vaccinated. Do you think getting more 
good information out, particularly in communities of color, 
about the success of vaccinations, would really be helpful?
    Ms. Ramos. Yes. I had to do my own research. I was scared 
to get vaccinated. I talked to my union rep about the vaccine, 
and I got the information. But I think most of my co-workers, 
they felt the same way I did. They did not want to be guinea 
pigs of the system, because what we went through was horrible. 
We did not get the help that we needed, and we felt like the 
companies just wanted us to be the guinea pigs.
    But if there is more information in the community--because 
we all have different backgrounds, we all speak different 
languages, and we come from everywhere--so if there are more 
resources in the community that they trust, it would be easier 
for them to get vaccinated.
    So they should talk to the church members, or somebody who 
speaks their language, to the leaders of the communities, to 
help them out.
    The Chairman. You know, your point is so logical, it is 
almost like you are being too logical for Washington, DC, 
because you should not have to be a private eye to get this 
information. So we are going to follow up with you on that. And 
again, I just so appreciate your leadership.
    Dr. Konetzka, let me turn to you. I am very appreciative of 
the fact you mentioned the strike teams, because I think they 
are extraordinarily important in bringing the expertise to this 
issue. We had a floor fight during our 24-hour day where we had 
to defend it, and fortunately we prevailed.
    I would like you to amplify on your concern, because I 
share it, about private equity getting more involved in the 
field. Because my concern is--and I heard Ms. Ramos make 
another point, that she is concerned that all they are 
interested in is money and the like. This trend towards more 
private equity looks to me like something that the Finance 
Committee should be digging into. And I thought maybe you could 
amplify on your statement.
    Dr. Konetzka. I agree. I think it would be a good thing if 
the Finance Committee could look into this. The increasing role 
of private equity in nursing homes, along with other complex 
arrangements like the related-party transactions, is a problem.
    There is really interesting recent research showing that 
nursing homes bought by private equity subsequently have higher 
revenues, but lower staffing and worse patient outcomes. And 
when those revenues are coming from public funds, this is not 
acceptable. And I think regulators have been reluctant to 
interfere with ownership transactions in the industry, an 
industry that is mostly for-profit, but it may be time to do 
so--at least in the sense of transparency.
    So we should think about assistance, or potentially 
increasing reimbursement rates so that we at least know where 
the money is going, even the current reimbursement rates.
    The Chairman. We are going to be calling on you again on 
this issue, because it seems to me this is an area that has not 
gotten the oversight and the accountability that is needed. And 
I am glad that you have lit this concern up in front of the 
Senate Finance Committee.
    A question for you, Ms. Moten, and I so appreciate your 
Ombudsman role. When I was director of the Gray Panthers, we 
worked with the Ombudsmen. And dollar for dollar, you all make 
such a big difference.
    We have been reading about how these rating systems are not 
doing a particularly good job of rating. What would you do with 
these and have, as counsel for the Finance Committee, some 
direction at improving them?
    Ms. Moten. You know, honestly I am not exactly certain what 
I would do to change the rating system. I think that a lot of 
what we see as Ombudsmen is that facilities are on their best 
behavior when help is in the building oftentimes.
    And so I think that some more impromptu approaches to that 
will probably be the best way to work through those issues.
    The Chairman. Well, three cheers for getting us started on 
that because, when I was on the nursing home board, if they 
knew you were coming, everything was perfect. And that is a 
very important suggestion. We will call on you again.
    All right, I am over my time. And our next member, we see 
our friend, Senator Crapo.
    Senator Crapo. Thank you very much, Mr. Chairman.
    And I will start with you, Mr. Dicken. In your testimony, 
you mentioned a statistic, if I got it right, that the deaths 
in nursing homes had gone down by 80 percent by February. Could 
you give me that correct statistic again? And if that is 
generally correct, could you tell me, do you have an idea as to 
what we can attribute that reduction to?
    Mr. Dicken. Yes. Thank you, Ranking Member Crapo. And you 
do have it correct. What we have seen from reporting from HHS 
is that, from the peak of cases and deaths in nursing homes in 
December until reporting early last month, the cases and rates 
have declined by 80 percent. And we are pleased that that 
decline has continued even beyond early February.
    Certainly, you know, we are continuing to evaluate kind of 
what those factors are. There is still a need for continued 
vigilance. That is a sharper rate of decline than we have seen 
throughout the broader community. There have been declines in 
cases and rates outside of nursing homes, and while it does 
seem to be sharper, certainly the prioritization of 
vaccinations of nursing home residents and staff is a key thing 
to look at in why it is an even faster decline in the rates 
recently for nursing homes.
    Senator Crapo. Well, thank you. It seems to me that 
something must be being very helpful. Something is working. And 
we need to identify exactly what that is. And so I would 
appreciate your assistance in that.
    GAO has issued at least four reports regarding the Federal 
and State response to COVID-19 in nursing homes. And I do not 
want to use up all my time on this, because I have a few other 
questions for others, but you mentioned that Seema Verma had 
issued some recommendations that have not yet been implemented. 
And I believe that GAO has made a number of recommendations in 
its report.
    Could you pick just a couple, like one or two of the most 
important recommendations you think are yet to be implemented 
and need to be?
    Mr. Dicken. Yes, and I will be brief. As you noted, the 
former CMS Administrator had a commission that made over 27 
recommendations on ways, both short-term and long-term, that 
CMS could help respond to the pandemic.
    CMS took a number of steps, but we have recommended that 
they do a more systematic plan on how they can more fully 
continue to draw from the expertise of the commission that was 
appointed, and we would recommend that that would help improve 
the Federal response.
    The other one I would highlight is that the data is very 
important for oversight, and for transparency, and that prior 
to May, that was voluntary. And we recommend that CMS identify 
a strategy to have more complete data for the early months of 
the pandemic. That is very important not only for ongoing 
response, but for understanding lessons from the pandemic over 
the course of time.
    Senator Crapo. Well, thank you. We want to work with you, 
and with all of our witnesses. I know our Ombudsman--and I will 
not be able to get to you in my questioning--but there are a 
lot of recommendations out there from all of you.
    We need to know what is working and what needs to be done 
better, and I encourage you to give us that information.
    I would like to move quickly to Dr. Gifford. Doctor, how 
did the AHCA respond to certain State directives mandating that 
long-term care facilities admit active COVID-19 cases?
    Dr. Gifford. Well, thank you, Senator Crapo, for that. I 
think, as we heard from Ms. Ramos and others, there was just 
chaos in May and April. The nursing homes were terrified of 
this COVID. Families were terrified. Staff were terrified. And 
hospitals were terrified.
    We saw in some cities, you know, lines forming in 
hospitals, and creating intensive care units in the parking lot 
in tents. And so there was sort of a lot of trying to figure 
out what was going on out there. And as a result, we saw 
variations and different recommendations that were out there.
    Nursing homes typically play an important role in 
emergencies in that they take on patients out of the hospital 
to free up hospital beds to deal with the emergencies. In this 
situation, though, freeing up the beds and taking people out of 
the hospital could potentially lead to further spread, and so 
that was sort of a worrying concern that we had. But we 
realized we needed to play a role in the health-care decision, 
because any decision that was going to be made was going to 
have dire consequences.
    If you decide not to move people out of the hospitals, you 
move people into parking lots. If you move people into nursing 
homes, you might create spread. And our position was to try to 
create special units and make sure there was enough PPE and 
enough staff that were out there that was really lacking. And I 
think you have heard that from the testimony that was out here 
so far.
    Senator Crapo. Well, thank you. I see my time has run out. 
It runs out quickly. For those of you whom I did not get to, I 
will submit some written questions to you. And I would really 
welcome your responses to these. Thank you very much.
    Thanks, Mr. Chairman.
    The Chairman. Thank you, Senator Crapo.
    Senator Stabenow?
    Senator Stabenow. Well, thank you very much, Mr. Chairman, 
for doing this very, very important hearing. And I think we all 
know this last year has been a horrible situation. And we have 
to say this started with a lack of seriousness by the former 
President and the lack of action by the administration. And 
certainly that has been something that we have seen where, in 
nursing homes, it has played itself out in a very, very serious 
way.
    High-quality staff are what make high-quality nursing 
homes. And a recent report, as has been said, found that the 
average yearly turnover rate for nursing home staff was 128 
percent. So 128 percent means the average staff completely 
turned over in a year. And some nursing homes had staff that 
changed over every few months, which is a very, very serious 
issue, obviously.
    Ms. Ramos, first of all I want to thank you for your 
incredible work, particularly over the past year. I am really 
in awe of your courage and your resolve, as well as the 
colleagues that you work with.
    You said at one point you were caring for 26 critically ill 
patients. Can you talk a little bit more about the impact of 
staff turnover on patient care?
    Ms. Ramos. Thank you for your question. So on the Mother's 
Day of last year, we had critically ill patients with COVID. 
They were all in bed. So there was me and another aide for 26 
residents, and a nurse and a housekeeper.
    We had to, you know, check their temperature, check their 
oxygen every 15 minutes. I was in an Alzheimer's unit, so it 
was very challenging, because our residents kept taking off 
their masks. So we kept going to their rooms because the oxygen 
was dropping, because they could not keep their masks on.
    So the quality of care, it was horrible. We were only two 
CNAs. And most of our residents were in bed. We could not sit 
there with them and talk to them while they were dying. We 
could not keep them hydrated when we knew that that was a part 
of it, that you had to keep them hydrated because they could 
not hold a glass of water.
    So we had to pick and choose, which is a thing that we have 
to do all the time--this did not start with COVID. So sometimes 
we have to pick and choose who are the critical residents for 
us to assist first. And that is a thing we do every day. And I 
do not think we should be put in that position where we 
constantly have to pick and choose what resident to care for, 
because we love them. We care for them. And the quality of care 
that they deserve is not there right now.
    Senator Stabenow. Well, and from your perspective--this 
sounds horrible, trying to figure this out when you can, and I 
am sure you are doing everything you can to care for people. 
From your perspective and your experience, what are the main 
reasons that nurses and CNAs leave their jobs at nursing homes?
    Ms. Ramos. Well, we do not want to leave our jobs. I had a 
thought, you know, during this pandemic. I was like, ``I cannot 
do this anymore.'' But then I said to myself, ``You know, right 
now is when they need me the most.'' So why would I leave them 
when the family members cannot come in? So I got up, sticking 
it out, and went back to work, because they need me.
    The reason why a lot of CNAs and nurses leave nursing homes 
is because the workload is a lot. We are constantly working 
short-staffed, and we, the CNAs, we make low wages. And we have 
to work in multiple nursing homes to pay our bills.
    So we do not want to leave nursing homes, but we have to do 
what we have to do for our families.
    Senator Stabenow. Of course. And I hear over and over again 
from our nursing homes that are really doing quality work as 
well, that not having enough nurses, right, and CNAs, is also, 
along with pay structure, really an issue.
    One of the things right now is, staff turnover information 
is not made public, and it seems to me that that would be 
important for patients and families.
    So if I might ask, Dr. Konetzka--you are on the Technical 
Expert Panel that advises CMS. Do you agree this information 
should be made public?
    Dr. Konetzka. Yes. I think turnover information is really 
important. There is a large body of literature tying higher 
turnover to worse patient outcomes in nursing homes. So I think 
that information could be useful.
    I think there are bigger gaps in terms of what we report, 
such as quality of life and customer satisfaction. But knowing 
turnover could be helpful to consumers.
    Senator Stabenow. Thank you. And then just finally--I know 
I am running out of time--but, Dr. Konetzka, in your opening 
statement you included recent findings that nursing homes with 
higher proportions of non-white residents experienced death 
counts three times higher than those facilities with higher 
proportions of white residents.
    So, like in many other areas, we have seen longstanding 
racial disparities put under bright lights, under COVID, 
certainly. But could you, based on your research--what would 
your recommendations be to address this?
    Dr. Konetzka. I would divide that into short-term and long-
term recommendations. I think in the short term, we need to 
make sure the assistance gets to those facilities and 
communities of color, because they are the ones experiencing 
the worst outcomes. So strike teams, for example--we have to 
make sure they get to those facilities.
    I would say also with vaccinations, we do not have the data 
to know this. The data need to be released. But we need to make 
sure that vaccination is equitable, and that people in nursing 
homes in communities of color, and people out in the community 
in those same neighborhoods, get vaccinated.
    The Chairman. This is an incredibly important topic, and we 
are going to return to it. We just have to move on because we 
have so many other Senators waiting.
    Senator Stabenow. Thank you.
    The Chairman. Our next Senator is Senator Grassley.
    [No response.]
    The Chairman. No Senator Grassley.
    Senator Cantwell is next.
    Senator Cantwell. Thank you, Mr. Chairman. Thank you for 
holding this important hearing.
    The State of Washington was one of the first States to 
record the impact of the COVID-19 virus. And many people may 
remember, on February 10th the Life Care Center in Kirkland, WA 
reported an outbreak of COVID-19 within the facility that 
ultimately would claim 46 lives.
    In the State of Washington, nearly half of the reported 
deaths have been in long-term care facilities. That is why in 
the American Rescue Plan there is included $750 million of 
support for nursing homes and skilled nursing facilities, 
including $500 million for strike teams and $200 million for 
infection control. This was something my colleague, Senator 
Casey, in his leadership made part of the COVID-19 Nursing Home 
Protection Act, which I also co-
sponsored with him, which was very important legislation.
    This, I believe, is critical, so I would like to ask Dr. 
Konetzka how this utilization of both strike teams and staffing 
issues can help protect nursing home residents during these 
times of major outbreaks?
    Dr. Konetzka. Thank you for that question. I think the 
strike teams are essential. I think they have been a good tool 
all along for States that have decided to do that. The problem 
is that nursing homes, even prior to the pandemic, were often 
under-staffed. And the pandemic exacerbated that, for all the 
reasons we have been talking about.
    Staff were sometimes getting sick, or afraid to bring the 
virus home to their families, or needed to stay home with kids 
who were learning online. And so you really could not implement 
the best practices that we now know can address a COVID 
outbreak, such as testing all residents as soon as there is a 
case in the facility, such as separating residents and 
assigning dedicated staff to COVID-positive versus COVID-
negative residents so they do not have to go back and forth 
between the two.
    All of those things take staff. And in the short run, we 
cannot incentivize facilities into finding more staff and 
hiring them in the middle of a crisis, in the middle of an 
outbreak. And so the strike teams are really essential to fill 
those gaps. Time is essential. Once you have an outbreak, you 
really need to deal with it immediately. And that is what the 
strike teams enable.
    Senator Cantwell. Well, my question is, what else can you 
do in the coordination? I think in this case the pandemic was 
new to the United States. We were at the very first impact; 
Life Care Center of Kirkland was at the very first initial 
impact. In fact, I think the University of Washington stepped 
in and tried to help, both in identifying and testing, but it 
was almost that, at that point, we needed more leadership 
beyond just the facility itself.
    So what else should we be doing to consider the 
coordination with the strike teams of almost, if not global 
technically, but theoretically global input to help on these 
crises?
    Dr. Konetzka. Yes, to me this is about policy leadership as 
well. I think the strike teams have mostly been facilitated 
through States. And the strike teams need to come, of course, 
with some coordination and technical assistance.
    There needs to be State leadership to identify which 
nursing homes really need this help, and coordination in 
getting them there and filling the necessary gaps.
    Senator Cantwell. Do you think we have these protocols in 
place now?
    Dr. Konetzka. I think it is unclear. I think there are 
still some things that need to be worked on in terms of overall 
coordination.
    Senator Cantwell. I think you are right too. That is why I 
asked the question. I think we really need to think about this 
in the sense of protocols that need to be established, because 
this is such a painful experience for everyone. And I think 
knowing how we could improve upon it in, not just the strike 
teams but the larger coordinated effort in marrying everything 
together, I think that would be great.
    Thank you so much. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cantwell.
    And our next questioner will be Senator Thune.
    [No response.]
    The Chairman. Senator Thune, are you out there?
    [No response.]
    The Chairman. Senator Menendez?
    [No response.]
    The Chairman. Senator Portman?
    [No response.]
    The Chairman. Senator Cardin?
    [No response.]
    The Chairman. Senator Toomey?
    [No response.]
    The Chairman. Senator Brown?
    [No response.]
    The Chairman. And I see Senator Cassidy.
    Senator Cassidy. Super. Am I up?
    The Chairman. Yes.
    Senator Cassidy. Good. Let me ask this, because when I 
speak to providers--I will probably go first with you, Dr. 
Gifford. I spoke to folks back home who ran nursing homes. They 
had an incredible problem with staffing during the pandemic. 
And what they told me is that the initial stimulus checks that 
were as generous as they were--as we know, about 80 percent of 
folks were making more money on stimulus checks than they were 
working--killed their ability to recruit staffing.
    Now this does not address the longer-term staffing issues, 
but it does beg the question of whether or not the decrease in 
staffing associated with the pandemic could have been 
associated with government policies which in effect paid more 
to folks not to work than to work.
    Dr. Gifford, any thoughts on that? And then I will probably 
come back to you, Dr. Konetzka.
    Dr. Gifford. Thank you, Senator Cassidy. You know, we have 
heard, I think from all of us, that the workforce is a 
challenge, and it was exacerbated with COVID. A lot of health-
care workers were home sick and could not come in, so that even 
made it worse.
    We did put together a training to train many of the 
unemployed who were out there, and we had over 200,000 people 
come through training to be temporary aides, whom we would love 
to see get into permanent aide positions and move on to become 
nurses out there.
    So there was a lot of demand for people coming in and 
helping to work. I think a lot of it was more around the 
licensure and the bureaucratic aspects of getting health-care 
workers into this sector. That was the biggest challenge that 
we faced, and we are really thankful for many of the States and 
the Federal Government for some 1135 waivers to make that more 
effective.
    Senator Cassidy. And, Dr. Konetzka, it does seem intuitive 
to me though, that if somebody can make 20 percent more on 
transfer payments as opposed to working--and if you are doing 
so, by the way, it suggests that you are kind of economically 
challenged to begin with--that there was an incentive for folks 
to retire from the workforce in order to do this.
    You are the economist. What are your thoughts?
    Dr. Konetzka. Nobody has collected data on that. I think 
what I have found anecdotally from talking to people who work 
in nursing homes is that that really was not a major reason why 
nursing homes were under-staffed.
    And I think when you look at people who work in nursing 
homes, some of whom are on this panel, people generally have 
different motivations for doing that work. And you really 
cannot be in it for the economics solely, if you work in a 
nursing home for low wages, take care of people, endure 
sometimes really physically and emotionally taxing work.
    So I would guess--although we do not have data on it--that 
a lot of the workforce shortage had to do with pandemic-related 
reality--getting sick, having family at home that you do not 
want to bring the virus to, or having kids at home--plus 
competition from other sectors. Hospitals were also competing 
for these same workers----
    Senator Cassidy. So let me ask you----
    Dr. Konetzka [continuing]. So I don't think incentives were 
a major force.
    Senator Cassidy. Got it. Let me ask you this. Again, if I 
speak to folks from the industry, they will say that many of 
them--and we noticed the racial disparity among those 
affected--that the racial disparity suggests--we do not know 
for sure--that the nursing homes most impacted were those which 
are most likely to have Medicaid as a primary payer.
    Now to what extent do low reimbursement rates affect the 
ability of someone to have that extra resiliency required to 
handle something like a pandemic? I will stay with you, Doctor.
    Dr. Konetzka. Okay. Are you asking about the resiliency of 
the workers themselves?
    Senator Cassidy. No, the nursing home. The ability to have 
that kind of redundancy of systems, the extra supplies on hand, 
the kind of--and really now, I am a doctor. So I walk into an 
older nursing home, and the rooms are smaller. The halls are 
more narrow. If you walk into something built for assisted 
living in which there is a payer mix, in which there is not 
just Medicaid but there is also private pay, you end up having 
better facilities, frankly, newer, better kept-up.
    So to what degree do low Medicaid reimbursement rates 
impact the ability of a nursing home to be better prepared for 
an incident such as we have seen?
    Dr. Konetzka. I think it is a big problem. There is a lot 
of controversy here. I think that the long-term care system in 
this country is generally underfunded, and a lot of that is 
because we depend on Medicaid. And the Medicaid rates in 
nursing homes in many States are really quite low.
    When we look at the high Medicaid facilities, they tend to 
have the lowest staffing ratios. They tend to have very little 
slack. They are always putting out yesterday's fires. And when 
you are hit with something like a pandemic, they are the least 
likely to be able to deal with it.
    Senator Cassidy. We are over time, so I will ask you a 
question for the record. If you did a regression analysis 
controlling for your payer mix being predominantly Medicaid, 
how much does that obviate the racial aspect of this, knowing 
that there is somewhat of a correlation between race and being 
on Medicaid as a primary payer? We are out of time.
    And I just want to give a shout-out to Denise from 
Louisiana. Denise, good to see you. It is always wonderful to 
see a friend as a panelist.
    I yield back.
    The Chairman. I thank my colleague.
    Next is Senator Portman.
    Senator Portman. Thank you, Mr. Chairman, and thanks for 
fitting me in. I want to talk a little bit about home and 
community-based services, and get the reaction from this great 
panel of witnesses.
    In Ohio, about 40 percent of our COVID deaths were in 
nursing homes. And that is not atypical, unfortunately, around 
the country. We tend to have a little higher percentage of 
people in nursing homes than in other States--but 40 percent. 
This makes it really the focus, and really the worst part of 
our crisis: 7,000 nursing home residents in Ohio lost their 
lives over the past year.
    It has improved recently, dramatically, because of the 
vaccinations, and I am excited about that. But in the meantime, 
it has been a huge problem.
    Long-term care of course is really important to ensuring 
seniors, and people with disabilities, can live meaningful 
lives. And while nursing homes are essential to our country, as 
is a long-term care system, they are not the only ones who 
offer this care.
    For years, I championed this push towards home and 
community-based services, or HCBS, where we can offer long-term 
care in residential settings that are more personalized and 
allow beneficiaries to live in their own homes, near to their 
family and their friends and their familiar surroundings.
    This is what we know about HCBS care: it costs less than 
nursing home care; it produces similar or better outcomes; and 
people are happier in it. Furthermore, Ohio data has shown that 
only .3 percent of all beneficiaries with severe disabilities 
receiving HCBS died of COVID this past year, or about 120 
deaths. So it was more successful in avoiding the fatalities 
with regard to COVID.
    Because it works, last year we passed two major efforts 
that the chair and ranking member and others have supported. I 
appreciate that. We passed the Ensuring Access to DSPs Act, 
which allows people on Medicaid to use direct support 
professionals for HCBS care, to have them assist with their 
hospital care, to help improve outcomes, and to get them back 
home quicker.
    That was really important, particularly for the 
disabilities community, and Medicaid helps cover that. We also 
passed the EMPOWER Care Act, which authorizes the Money Follows 
the Person program for 3 additional years. I would like to have 
gone further on that, and again many colleagues on the other 
side of the aisle have helped on this. But it helped transition 
people from nursing homes to HCBS care.
    My question to the panel is this: when the pandemic was 
beginning, what could we have done to have better utilized HCBS 
services to have potentially prevented some of these deaths? 
And second, what policy changes should we now consider in order 
to further promote such services?
    And it is open to the panel.
    Dr. Konetzka. I will start. I think it is a--I thank you 
for your efforts to expand home and community-based care. I 
dream of a system where the funding mechanisms are smooth 
between nursing homes and home and community-based care, and 
people and policy-makers can decide how to target that care 
appropriately, and people can get care where they would like.
    I only caution that it is not a panacea, that we probably 
will always need nursing homes. And there are some cases in 
which home and community-based care can lead to worse outcomes. 
I think we have to be very careful about targeting, but I think 
that expansion of home and community-based care in a pandemic, 
or beyond, is critical.
    Senator Portman. Thank you.
    Mr. Dicken, have you looked into this for GAO?
    Mr. Dicken. Yes; thank you. It is certainly a really 
important question. I certainly agree that it is important, 
especially in the sense to make sure that, at any time, people 
are getting appropriate long-term care in the appropriate 
setting.
    In this area, there is much less Federal information and 
data on what is occurring in home and community-based settings, 
or assisted living and nursing homes. I know that today's 
hearing is focused on some of the limitations on what is known 
within nursing homes.
    You were able to indicate some Ohio-specific information, 
and there is information at the State level. But many of the 
same vulnerabilities exist for the population that is at risk, 
that needs direct support.
    And we have heard similar types of challenges, of things 
like having adequate protective equipment, staffing challenges. 
So similar types of challenges may be less of a problem in a 
congregate setting, in some other settings. But also there is 
much less information at the Federal level on what is occurring 
in settings outside of nursing homes.
    Senator Portman. So more data is needed. And if we had that 
data, we would have a better understanding of what the 
different outcomes are.
    Mr. Dicken. That would be helpful, yes.
    Senator Portman. Ms. Ramos, or Dr. Gifford, any thoughts?
    Dr. Gifford. Go ahead, Ms. Ramos.
    Ms. Ramos. I think that, in the nursing homes, we need 
oversight. And Congress is the only one that can have that law 
passed. Right now, we are fighting on the State level, but it 
is not just in our State that we have these issues in the 
nursing homes. It is across the country.
    And our union is fighting really hard for us to pass the 
bill so that everyone in the State, and in this country, will 
have a law that will support the staff and the patients' 
quality of care.
    Senator Portman. Thank you, Mr. Chairman.
    Dr. Gifford, if you have additional thoughts, I would love 
to hear them, maybe with a written response. Thank you, very 
much. Thank you, Mr. Chairman.
    The Chairman. Senator Cardin was here before Senator Brown. 
I apologize to my colleagues for the juggling. Senator Cardin 
is next, and then Senator Brown.
    Senator Cardin. Well, thank you, Mr. Chairman. I appreciate 
that very much, and I appreciate the panel. This is obviously 
an extremely important subject. We know that nursing home 
safety has been a critical part of dealing with COVID-19.
    I appreciate the challenges that we have had with 
personnel, with safety of the personnel as well. I want to talk 
about an issue that was present before COVID-19, and that is 
that nursing homes have----
    [Pause.]
    The Chairman. Senator Cardin, we seem to have some audio 
issues on your end. Can you hear me?
    [No response.]
    The Chairman. Why don't we go to Senator Brown, and then we 
will go to Senator Cardin.
    Senator Brown. Thank you, Mr. Chairman.
    Just last month researchers from leading institutions 
across the country published a working paper on private equity 
investment in health care, specifically nursing homes. They 
studied Medicare data from 18,000 nursing home facilities over 
a 12-year period, examining patient outcomes at private, 
equity-owned facilities.
    The results are disturbing. Let me quickly summarize. 
Researchers found private equity firms tend to shift money away 
from patient care, cutting the number of hours that front-line 
nurses spend providing care to patients. They also--and Ms. 
Ramos, I am sure, is familiar with this, because of the union 
that she is a part of that represents some of these workers--
they also found that patients at private equity-owned 
facilities were more likely to be given anti-psychotic drugs. 
They found that patients who receive care at private equity-
owned facilities are more likely to die. In fact, the 
researchers found that more than 20,000--20,000--Medicare 
beneficiaries died as a result of private equity-ownership of 
nursing homes during that sample period of 12 years. Finally, 
they found that taxpayer spending per patient episode increased 
by 11 percent.
    To summarize, the study found that when private equity 
firms acquire nursing homes, they cut staff, they prescribe 
more dangerous drugs, more patients die, and taxpayers pay more 
money.
    In November 2019, Senator Warren and I sent letters to four 
private equity firms that invest in nursing home care and other 
long-term care services to request information on how these 
private equity firms manage their facilities.
    So, Mr. Chairman, I would like to ask unanimous consent to 
enter this paper by Atul Gupta and his colleagues, as well as 
the letters that Senator Warren and I sent out to these private 
equity firms and their responses, into today's record.
    The Chairman. Without objection.
    [The documents appear in the appendix beginning on p. 61.]
    The Chairman. And I would note, Senator Brown, I have been 
asking some of those same questions, so I very much appreciate 
it. Go ahead.
    Senator Brown. Thank you. We also see this private equity 
issue--I'm the new chair of the Banking, Housing, and Urban 
Affairs Committee. We see private equity firms, starting in 
Iowa, we believe, but all over the country, private equity 
firms buying up manufactured housing, so-called trailer parks, 
and squeezing those generally low-income residents.
    So we see it throughout our economy. My question--and I 
have a follow-up question too--Ms. Ramos, two questions for 
you.
    First--and make your answer as short as you can--talk about 
the difference between what adequate staffing and an under-
staffed shift means for your patients, and what it means to you 
and your colleagues, if you would, Ms. Ramos.
    Ms. Ramos. Thank you for your question. So with more 
staffing, we can give the residents better care. For example, 
if a resident asks me--if two residents ask me to go to the 
bathroom, I have to pick and choose which one of them to take 
to the bathroom first.
    So when we have more staff, another aide can help the other 
one. But when we are short-staffed, if I am in the bathroom 
with one of the residents and a patient has fallen, like a 
patient fell in the dining room, the nurse is calling for help, 
we have to leave the resident who is in the bathroom and go to 
help the other resident who just had a fall.
    So those are the types of things that we have to do all the 
time. We have to pick and choose which resident we have to take 
care of first. And it is a challenge for the nurses and for the 
CNAs that we deal with every day.
    Senator Brown. Thank you for that good, concise answer. 
Throughout COVID, higher nurse staffing levels have been 
associated with fewer COVID-19 cases and deaths. We know that. 
I have introduced legislation in this committee to require 
hospitals to maintain safe staffing levels. And I know Chairman 
Wyden wants to do this and consider ways to improve nurse-to-
patient staffing ratios at long-term care facilities.
    My last question, Ms. Ramos--I notice your T-shirt, and I 
know you are a proud member of the Service Employees 
International Union. Talk to me about how being part of a union 
has allowed you to better advocate for your patients.
    Ms. Ramos. Being part of my union helps me advocate for and 
be a voice for the workers who do not have a union, and the 
patients who do not have the family members who will stick up 
for them.
    And we do that across the country. And also, when we are 
united and we have power--so with that power, we got hazard pay 
during the pandemic. And to make our voices heard and really 
inspire change, that is the reason why I am here today telling 
you our stories in a nursing home.
    Senator Brown. Thank you, Ms. Ramos. Thanks for your 
conciseness.
    Mr. Chairman, my time has expired. Thanks very much for 
having this hearing, Chairman Wyden.
    The Chairman. Thank you, Senator Brown.
    Our next--we've got Senator Cardin back; wonderful.
    Senator Cardin. I think I am with you now. We changed the 
connection.
    The Chairman. Perfect.
    Senator Cardin. Thank you very much. First, thanks for this 
hearing. It is very important.
    Ms. Ramos, I want to thank you and all the front-line 
workers for what you have done during COVID-19. You truly have 
stepped up to help our community, and we thank all of our 
front-line workers during this time.
    It has been very challenging. We know of the circumstances 
when personnel become difficult because of getting COVID-19, 
and protecting our workers, and protecting the residents at 
nursing homes. It is a real challenge.
    We recognized this before COVID-19. And that is why we 
looked at the issue of infection prevention in nursing homes. 
In 2016, the Obama administration issued certain regulations in 
regard to the requirements for nursing homes. The Trump 
administration reduced some of those requirements.
    I guess my question to you is, do we have adequate Federal 
guideline protection to deal with ongoing issues of infectious 
diseases? Look, COVID-19--we will get beyond that at some 
point--but there are going to be other issues that are going to 
come up that affect the health of the nursing home residents 
and the personnel who work in nursing homes.
    Are we doing enough as far as Federal guidelines to require 
nursing homes to have adequate protection to deal with 
infectious diseases? Whoever wants to answer it, I welcome your 
thoughts.
    Mr. Dicken. This is John Dicken with GAO, and I can just 
note that certainly even making the point that you made is 
important, that even before the pandemic we found that the 
highest source of deficiencies that were found in nursing homes 
was for infection control.
    And so it is essential that there be focus even outside of 
this pandemic environment on trying to control and prevent 
infections, and to apply appropriate infection control 
practices. That is a requirement: that the nursing homes have 
plans to be able to prevent and control infections. Even before 
this pandemic, that was the primary type of deficiency that was 
found in nursing homes.
    Senator Cardin. So I guess my question to all of us is 
that, obviously, a lot of this can be done administratively, 
but we in Congress might need to take a look at policies that 
reflect that.
    One of my interests is how we share best practices. We know 
that nursing homes have come up with creative ways to protect 
their residents, and to protect their essential workers. Is 
there an adequate communications system within the nursing home 
industry itself to implement the best practices that are being 
used around the Nation? And is there a way that the best 
practices can make their way to us policy-makers so that if we 
look at legislation, we look at what is working and what is not 
working and try to develop the best policies for our country?
    Again, I welcome anyone on the panel who wants to talk 
about that, as to how we can take the best practices that are 
being used today to keep nursing home residents safe, and the 
personnel safe, and how we can implement that in Federal 
policy.
    Ms. Ramos. This is Adelina. From my experience, we need to 
have oversight in the nursing homes. And the Senate is the only 
one that can do that.
    We tried working on it through the State to have a law 
passed so we could have safety and better quality care for our 
residents, because before the pandemic, like you said, we had 
this problem. And with the pandemic, it made things worse.
    So it is not just a State-by-State problem, it is across 
the whole country. Because my story is not unique. If you ask 
anybody else in any other States, they have similar stories. 
They have seen similar things, or worse, of what I have been 
through.
    So I think Congress has the power to change the laws across 
the country.
    Senator Cardin. And I think the SEIU can play a major part 
in that. You have people around the country who have seen what 
works well, and what has not worked, and I think sharing that 
information with us would certainly be very helpful as we try 
to deal with this issue moving forward.
    We have to look at the lessons learned as a result of 
COVID-19, recognizing that infectious disease spread within 
confined nursing homes is going to be an ongoing challenge in 
regards to the safety of people in this country.
    Thank you, Mr. Chairman. I thank our witnesses.
    The Chairman. Thank you, Senator Cardin. Next will be 
Senator Lankford, and then Senator Casey, and I hope we can get 
both of them in. We have a vote going on.
    Senator Lankford?
    Senator Lankford. I will hustle, Mr. Chairman. Thank you 
very much for doing that. I have been a very outspoken advocate 
for, obviously, safety in facilities, in all of our long-term 
care facilities, as all of you have been as well. So I 
appreciate very much what you are doing for this.
    But I have also been an advocate to say many individuals in 
my State--in fact, all the individuals who want it in my 
State--who are in long-term care facilities have already been 
vaccinated, both the staff and the individuals. Some of them 
were vaccinated 5, 6 weeks ago and have been through the full 
regimen and been on the other side of it.
    There is a difficult balance there of trying to provide 
safety to those individuals, but also to have access to their 
grandchildren, their families, and other individuals, school 
groups that want to be able to come in and bless them.
    What they have seen is some normal activity in the past 
around the facility in trying to strike that balance. CDC has 
put out some guidance. States, including my own State, have put 
out some guidance on their own. Sometimes they are not lining 
up.
    So my question on this is, based on where we are right now, 
what would you recommend that we put out as guidance for 
individuals who are dealing with real depression and real 
isolation in a very difficult season of life already? What 
would you recommend we start to do right now for those who have 
already been vaccinated in the facility? So I open that up. Dr. 
Gifford, obviously you are going to be the obvious one on this, 
but I would open it up to anyone else who wants to be able to 
respond to that as well.
    Dr. Gifford. Well, I think--I am glad you are raising that 
point. And I think we have all seen--the families and health-
care givers--that when you take a frail elderly person and 
restrict them from seeing their family, and they cannot 
participate in activities with the other residents, and really 
have trouble interacting with the staff as well because many of 
them have dementia and they do not understand what is going on, 
it will have dire consequences with them.
    And I think the challenge is when you balance the safety of 
a virus that has a 20-percent mortality risk with the clearly 
devastating impacts you have had with that. I think we are 
transitioning out of that, which is good.
    I think this raises just a broader question about how do we 
move to provide the care, activities, and infection control 
when you have to restrict people's movements around in a 
building?
    Senator Lankford. Other comments from other individuals?
    Ms. Ramos. Yes, please, I would like to add to that. I 
think in large part, on the temporary nurse aides, and how 
people have gone and gotten the certification to be able to 
work in facilities but may not have all the credentials, I 
think from a logistical standpoint, just simply put, we could 
allow families to take the same type of training for infection 
control and universal precautions and allow for the designation 
of essential caregivers, so they are able to be in there, and 
able to come in and help supplement the care the staff may not 
be able to provide.
    A lot of these people were going to see their families 
weekly prior to COVID, and so I think it is just one of many 
solutions that we could look at across the board. And you know, 
in working through that, they would still be held to the same 
requirements as staffing in terms of testing and, ideally, 
vaccinations.
    Senator Lankford. Do others want to be able to comment on 
that?
    Dr. Konetzka. I will just add that the essential caregivers 
programs that were just mentioned, a handful of States at least 
implemented these even before the CDC opened up guidance about 
visits. And those may serve as a model, as a good model for how 
we should be moving as a country. Those are programs in which 
some family members could go in on a regular basis, and they 
took all the precautions that staff took, and I think those 
were generally very successful.
    Senator Lankford. So would you recommend something like 
this in--let's skip past COVID. We are all looking forward to 
that day. We are past it. In whatever that looks like for us, 
we will still have tough choices in the days ahead. And 
obviously, a really difficult flu can have a catastrophic 
effect inside of a long-term care facility as well.
    Would you recommend some of these same processes be carried 
over into a difficult flu season as well, for individuals in 
long-term care?
    Dr. Konetzka. Perhaps. But I think it is important to 
remember that reducing physical risk is not the only goal here. 
We need to find the right balance between quality of life and 
seeing family and friends, and reducing physical risk. I think 
the goal is probably not zero risk; the goal is to find the 
right balance.
    Senator Lankford. I am glad to be able to hear you say 
that, because there does seem to be a concern about how we get 
to zero risk. And zero risk has a lot of emotional damage on a 
lot of families, and a lot of individuals in their isolation. 
And some of the individuals that I interact with will say 
things like, ``I have been waiting for 10 months, and I've 
thought in my head over and over, once I get the vaccine this 
will be different.'' And they are experiencing right now 
nothing different for them, and they have had the vaccine.
    So they are trying to find some hope in the middle of this 
as well. So thank all of you for the ongoing work that you have 
done.
    The Chairman. Thank you, Senator Lankford.
    Senator Casey--and, colleagues, Senator Casey has done 
three separate reports on this issue. He has put an enormous 
amount of effort into it, and we appreciate it. Senator Casey?
    Senator Casey. Mr. Chairman, thank you very much for having 
this hearing. I want to thank you and the ranking member. And, 
Mr. Chairman, I want to thank you for the work you have done to 
hold the prior administration accountable on these issues that 
relate to nursing homes and long-term care, and to work with me 
and with others to move this agenda forward, which we still 
have much work to do in connection with. I am just grateful for 
this opportunity. Senator Whitehouse earlier, in his 
introduction of Ms. Ramos, was highlighting some of the work 
that he has done with us as well, and we are grateful for that.
    I want to start by offering at least, at a minimum, words 
of commendation to Ms. Ramos and other front-line workers. In 
your testimony very early on, you talked about, quote, ``days 
filled with fear and sadness'' in the work that you have done. 
And we want to commend that work.
    I was especially moved by the reference you made to when 
you had contracted the virus and were not able to hug your son 
as you would want. And so many Americans have felt the same--
that same sense of loss.
    And the moment you talked about sitting with a long-term 
care resident and wanting to hold her hand, but being pulled 
away to the work that you had to do because of staffing 
issues--so we want to thank you and SEIU for standing up for 
workers like you.
    We have to do more than offer words of commendation. We 
have to start voting with you--both parties, both Houses, both 
branches of government--to lift up the caregiving workforce. We 
are decades late in doing that. And so, I do not ask for your 
comment, I just want to let you know that we are thinking about 
you and realize that we have an obligation to you and those 
with whom you work.
    My question will be preceded by a little bit of background. 
I want to direct my question to Dr. Konetzka. We know that, as 
many of us have referenced, now more than 178,000 residents and 
workers in long-term care have died from the COVID-19 virus.
    This is a terrible, profound tragedy within the broader 
COVID-19 tragedy. We know that, in Congress, we have an 
obligation to learn from the tragedy and to deliver a common-
sense response.
    I worked with Senator Toomey, my colleague from 
Pennsylvania, on work we did in connection with the Special 
Focus Facility program. We did some investigative work and made 
some changes, but now we have legislation that we have just 
recently reintroduced: the Nursing Home Reform Modernization 
Act.
    It does basically three things. Number one, it expands the 
oversight of the Special Focus Facility program's Candidate 
Facility--that is a specific type of facility. Second, it 
increases the educational resources for the facilities that are 
underperforming. And third, it establishes an independent 
advisory council to inform Health and Human Services on how 
best to rank nursing home performance and foster quality 
improvements. I am grateful to be working with Senator Toomey, 
because some of this work can be and must be bipartisan.
    Dr. Konetzka, do you think that there is merit in expanding 
the size of the Special Focus Facility program to more 
facilities and enhancing the oversight of underperforming 
nursing homes?
    Dr. Konetzka. Senator Casey, first of all, thank you for 
your persistent efforts on the issues of nursing homes and in 
the area of disparities. I am fully supportive of your efforts 
to expand the Special Focus Facility program. We all know that, 
even though there are many nursing homes that provide very good 
quality of care, there is a bottom tier of nursing homes that 
are chronically problematic. And that is the tier of nursing 
homes that the Special Focus Facility program is aimed at.
    It has been a tiny program over the years, and I think you 
are absolutely right in wanting to expand that program and 
doing what we can to try to bring up that bottom tier.
    Senator Casey. Thanks very much, Doctor. And I know that we 
have about 30 seconds left, but just to ask quickly, Ms. 
Bottcher, with regard to transparency. I will just make it 
quick, without a prelude, to ask, what do you think we have to 
do to give families what they need to make informed decisions 
about nursing homes?
    Ms. Bottcher. Well, of course knowledge is power. And so, 
having transparent data available for families, making it easy 
to read, being consumer-friendly, that will go a long way to 
helping families understand what is going on with their loved 
ones.
    Senator Casey. We look forward to working with you and the 
rest of the panel.
    Thank you very much, Mr. Chairman.
    The Chairman. Thank you for the good work, Senator Casey.
    Senator Grassley?
    Senator Grassley. Thank you, Mr. Chairman.
    Since we are talking about nursing homes, I think I ought 
to start by saying ``thank you'' to every American who has 
supported our seniors during this pandemic, because our nursing 
homes house the most vulnerable that we have in our society. 
And this has been a very challenging year for these seniors, 
but it has also been a very challenging year for our health-
care workers.
    Before I get to my first question for Mr. Dicken and Ms. 
Moten, let me lead in with this. Last year, the Department of 
Justice launched an investigation into four States' COVID-19 
responses in nursing homes. These States were Michigan, New 
Jersey, New York, and Pennsylvania. They pressured nursing 
homes to admit residents who may have been infected with COVID-
19. The CDC recommended that hospitals discharge patients with 
COVID-19 diagnosis only to nursing homes that are capable of 
implementing all recommended infection control procedures.
    State officials who pressured nursing homes to admit 
untested or contagious COVID patients from hospitals likely 
increased the case rate and fatality risk for these residents. 
Meanwhile, State officials in other parts of the country--
Florida is just one example--followed CDC's guidance, often 
with better results.
    So to Mr. Dicken and Ms. Moten: how important is it for the 
Department of Justice to continue investigating these four 
States' violations of the civil rights of the nursing home 
residents and the failed duty to care?
    Mr. Dicken. Thank you, Senator Grassley, and I appreciate 
your long-term leadership on these issues. Certainly what we--
we are aware that there are both Federal and State-level 
investigations ongoing. GAO continues to examine what the 
experience has been across all States, as this has affected all 
States. And there are two key points on that.
    One, one reason why GAO has recommended that there needs to 
be more complete information that was only voluntarily reported 
at the Federal level on cases and deaths in nursing homes prior 
to May, is so that we can learn some of the lessons that we 
learned from the very uncertain and challenging times early in 
the pandemic.
    And secondly, we have talked to--our ongoing work looks at 
a range of States across the country, and we are hearing common 
concerns about how best to get protective equipment, dealing 
with protecting hospitals. And these are challenges that have 
been faced throughout the country.
    Ms. Moten. I want to echo the sentiments of Mr. Dicken. I 
think that it is important that we continue to investigate 
these four States in particular, and States across the country, 
as we are able to take those stumbling blocks and make them 
stepping stones.
    You know, the reality is that we could have done a better 
job in a lot of these places. And while oftentimes our care 
community mirrors what was going on in other communities, our 
hospitals were able to handle infection control. And so I think 
we need to look into this so that we are able to figure out 
what system breakdowns we had in those different States and 
better understand them, so we do not repeat those same 
mistakes.
    Senator Grassley. Both Republican and Democrat Senators 
have warned President Biden that he should not terminate 56 
U.S. attorneys, particularly those who have ongoing sensitive 
investigations.
    One is Toni Bacon, the U.S. Attorney, Northern District, 
New York. Ms. Bacon previously served as the Justice 
Department's National Elder Justice Coordinator and currently 
has jurisdiction over Federal public correction crimes in the 
State. The State of New York under-counted nursing home deaths 
by as much as 50 percent, and State officials intentionally 
withheld data for months. Ms. Bacon is the obvious choice to 
continue a fair and unbiased investigation into possible 
violations of civil liberties of the elderly and public 
corruption.
    So, to the same two people, Mr. Dicken and Ms. Moten, do 
you believe the U.S. Department of Justice must have a fair, 
unbiased, and experienced U.S. Attorney in the Northern 
District of New York, such as Ms. Bacon?
    When you get done answering, I will have to say my time is 
up. But let's hear the answer.
    Mr. Dicken. Thank you, Senator Grassley. I cannot speak to 
the specifics there, but I certainly know that there are fair 
and complete investigations at the Federal and State levels. 
But I have not looked at that specific situation.
    Senator Grassley. Ms. Moten?
    Ms. Moten. Again, I echo Mr. Dicken's position on that. I 
think that an unbiased party is definitely going to be needed 
to make the proper recommendations and to do a full 
investigation. But I cannot speak to the person you are asking 
about.
    Senator Grassley. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Grassley.
    Just one fact, quickly, before we go to Senator Menendez. 
When you look at the top 10 States with the highest number of 
COVID deaths per occupied bed, they are evenly split between 
States led by Democratic and Republican Governors, which 
supports the proposition this was not a blue State/red State 
issue. It is a huge national tragedy for the country.
    Senator Menendez?
    Senator Menendez. Thank you, Mr. Chairman.
    Mr. Dicken, last June I led my House and Senate colleagues 
in a letter to then-Secretary Azar, and then-Administrator 
Verma, pleading for more resources, guidance, and support for 
nursing homes. At the time, New Jersey had already been on the 
front lines of the pandemic for over 2 months--2 months when we 
were fighting in the dark against an invisible enemy; 2 months 
when New Jerseyians suffered immeasurable losses and pain.
    In that letter, I called for a comprehensive national 
testing plan. We did not get it. I asked for a strategy to 
ensure our nursing homes had sufficient PPE. I asked for a plan 
on staffing shortages, and how to care for COVID-19-positive 
residents. And I called for greater resources to improve 
reporting and communication.
    We did not get all of those things. And when we did get 
something, it came slowly and, for many, too late. So that we 
can learn from the past, can you talk to us about the harm 
inflicted by the failure to put in place a national testing 
plan last spring?
    Mr. Dicken. Yes; thank you. And right, that is part of the 
broader work in the Federal response to the pandemic. GAO has 
also recommended that there be a national testing strategy, and 
that has not yet been implemented.
    That is key for several reasons. The national testing 
strategy would help better target information on what resources 
and expertise can be used to try to control or prevent 
outbreaks. It also could ensure more consistency, so that 
State, Federal, and private entities work on common goals, and 
that there would be common information that could have more 
transparency.
    Senator Menendez. Thank you.
    Dr. Gifford, I recently introduced the PREPARE Act and sent 
a letter with Congressman Pascrell to the administration 
requesting that infection control practices be improved in 
nursing homes to combat the future spread of COVID and other 
viruses.
    Your plan also calls for a new focus on infection control 
by adding additional requirements to the infection 
preventionist position that is required in all facilities. 
Could you elaborate on your plan and how these changes would 
help provide a healthier environment for the residents you 
serve?
    Dr. Gifford. Thank you, Senator Menendez, for all of your 
efforts on both PPE and infection control. We definitely have 
supported the infection preventionist program and requirements 
since the beginning. I think what we have learned is that you 
need to tailor that infection preventionist to the needs of the 
facility.
    A large facility with 300 to 400 beds needs more than one 
person. A 20-bed facility in a rural community does not need 
the same amount. A facility that takes care of highly acute 
illness, and very sick individuals, may need more infection 
preventionists than those that have less acuity in there.
    And so we would strongly support it being evidence-based. 
You also do not want to say it has to be one person, because if 
that person gets sick or is out on vacation or not working 
those days, you want to have good coverage on infection 
prevention throughout. So this should be covered by multiple 
people.
    So we are asking for an evidence-based approach to 
addressing this infection preventionist in a nursing home.
    Senator Menendez. And one final question. Last week, the 
AHCA sent a letter to the administration asking for next steps 
for vaccinations at nursing homes. Now last week, we learned 
that in New Jersey only about half of our nursing home staff 
are vaccinated. Since the pharmacy partnership with retail 
pharmacies and nursing homes is drawing to a close, it seems to 
me we need to be sure we can still get people vaccinated in 
these facilities.
    What are some of the more creative ways the Federal 
Government can partner with our nursing home partners to reach 
the stated goal of 75 percent of staff vaccinated by June 30th?
    Dr. Gifford. Well, I think the initial plan they had, 
working with retail pharmacies and getting the vaccine out 
there, was a highly successful program. I think the challenge 
now is getting vaccine out. There just is not enough vaccine 
still coming out and being allocated into the program. And so, 
no matter how innovative a program you have, there is no 
vaccine being allocated out, other than for a handful of 
States.
    We need to not let the gains that we have seen with 
vaccinations slip. It is also clear, I think as you heard from 
Ms. Ramos, that you need to have multiple people sitting down 
and listening and talking to staff and residents about what 
their concerns are with the vaccine, so that they can 
understand what is going on out there. And CDC is sort of 
working in that area, and we support that effort.
    Senator Menendez. Thank you, Mr. Chairman.
    The Chairman. I thank my colleague. We are going to keep 
this going. Senator Crapo has been kind enough to say he will 
run the hearing while I run and vote. And I think I saw Senator 
Hassan. Perhaps she will be back soon.
    Senator Crapo, if you will run it, I will be back very 
quickly.
    Senator Crapo [presiding]. I will do so. Thank you, Senator 
Wyden.
    Do we have any Senators who are here at this time? Senator 
Thune?
    [No response.]
    Senator Crapo. Senator Barrasso?
    [No response.]
    Senator Crapo. Senator Warren?
    [No response.]
    Senator Crapo. Senator Hassan?
    [No response.]
    Senator Crapo. Well, if no Senator shows up, I will go back 
into some of my questions. Hold on a minute while I grab my 
stack of papers here.
    All right; thank you. I am going to go next to you, Ms. 
Bottcher. You put in your testimony--you have outlined a five-
point plan or a proposal that you are focusing on. I was 
interested--well, I was interested in all of those points. Your 
third point was basically to focus, if I understood it 
correctly, on safe access to in-person and virtual meetings 
between nursing home residents and their families.
    Could you expand on that a little bit? Are you saying that 
we need to increase in-person, or just make sure that we focus 
both on in-person and virtual?
    Ms. Bottcher. So, both in fact. And thank you for the 
question, Senator Crapo. AARP has advocated, when it is safe to 
do so, to allow for in-person visitation. And of course CMS 
updated those guidelines. But in-person visitation--we cannot 
lose sight of the fact that we still have to talk about 
infection control and follow those procedures.
    There still has to be adequate staffing to be able to 
provide and support in-person visitation and all the other 
guidelines that CMS has put forward--and so all of that. It is 
a delicate balance, as we have talked about. In-person 
visitation would certainly help those who have had some mental 
decline without that social connectedness. And it would help 
with the mental health of the person, but we also have to do 
everything we can to provide for the safety of that person with 
regard to COVID.
    Insofar as virtual visitation goes, we believe that 
Congress could do more to require that facilities facilitate 
virtual visitation when they cannot support in-person 
visitation. And of course we saw that throughout the pandemic 
with the use of cell phones, with the use of iPads. But this 
was not done consistently throughout nursing homes across the 
Nation.
    Senator Crapo. Thank you. I was just about ready to go to 
you, Dr. Konetzka, but I see that we may have Senator Thune 
with us. Do we? And if not, I do see Senator Daines.
    Senator Daines, you may proceed.
    Senator Daines. Right. Thank you, Senator.
    Well, I am glad to be part of this hearing today. This is 
something that has touched Montanans deeply. Over the past 
year, our Nation and my own State of Montana have experienced 
loss in so many ways. Our seniors have borne the brunt of this 
pandemic, in fact, so much so that States like New York have 
tried to cover up the true toll this pandemic has taken on 
nursing homes.
    The reality is that more than one-third of all U.S. COVID-
19 deaths are linked to long-term care facilities. We must do 
more to support our nursing home residents, many of whom have 
suffered with increased depression, anxiety, and worsening 
dementia due to COVID restrictions, and the isolation.
    Throughout the pandemic, residents were deprived visits 
from sons, daughters, new grandbabies, staring through windows, 
listening to recordings of loved ones to try to keep those 
memories alive. And we know that extreme social isolation can 
have very serious health consequences and can even be deadly.
    With nearly two-thirds of seniors having received their 
first shot, and millions of American being vaccinated every 
day, we are finally turning the corner. There is hope. Today, 
nursing home residents across the country can visit safely with 
their loved ones, and we have even seen examples of hugging 
their family members for the first time in a year.
    We are making great strides. We are getting shots in arms 
across the country, currently at a pace of over 2 million per 
day, but there are folks who are reluctant to get the vaccine.
    A February study by the CDC estimated low rates of vaccine 
uptake among nursing home staff at 38 percent, compared to 
nursing home residents at 78 percent. We need at least 75 
percent of the population to be vaccinated for us to achieve 
herd immunity and get back to normal.
    I decided to take part in the 5-year vaccine trial last 
year--it was offered in my home town of Bozeman, MT--because I 
want to do my part in helping to make Montanans feel confident 
about the vaccine.
    My first question is to Mr. Dicken. Can you describe how 
well vaccine distribution in nursing homes is going and provide 
any analysis on the CDC's study on vaccine uptake?
    Mr. Dicken. Yes; thank you, Senator Daines. And you are 
right that as nursing homes have been prioritized for vaccine 
distribution, more than 99 percent of homes that participate in 
the Federal partnership have had at least one on-site clinic 
that could help offer vaccines to residents and staff.
    That is more than 4.25 million vaccines that have been 
distributed to residents and staff in nursing homes as of early 
February. And that number continues to grow.
    Senator, the CDC numbers you cited are correct that have 
had a larger share of residents who have taken the opportunity 
to get the vaccinations, and that during the first clinics that 
occurred under the partnership, a smaller share of staff had 
agreed to take the vaccinations.
    There was hope that over time, as there continued to be 
more opportunity and clinics, that would increase. The comment 
that my fellow panelist, Ms. Ramos, her experience--as more 
staff see other colleagues who have been vaccinated and the 
decline in cases, we can only hope that that would increase 
their comfort with receiving vaccinations.
    Senator Daines. Thank you.
    I have a question for Ms. Bottcher. Last year I teamed up 
with Senator Grassley on a bill that would allow for the 
creation of strike teams in States to help facilities that were 
being overwhelmed by COVID-19. This bill also supported tele-
visitation programs so that nursing home residents would not be 
as isolated from family in the stresses of the pandemic.
    Ms. Bottcher, can you speak to the benefits of virtual 
visits in lieu of in-person visits, and what barriers prevent 
residents from accessing tele-visit technology?
    Ms. Bottcher. Certainly. Thank you so much for the 
question. AARP has long been supportive of virtual visits. And 
we have--when the pandemic unfolded and nursing homes were 
closed, families were shut off from their loved ones. And a lot 
of them did not already have that set up with their loved one.
    And so it was incumbent upon nursing homes to facilitate 
that to the best extent, where they could. I think the 
shortcomings were the infection rates. As they rose in 
facilities with residents and staff, then you did not have 
enough staff to facilitate those virtual visits. You had some 
nursing homes that were concerned about passing around the 
technological devices to be able to facilitate that.
    So there just was not a lot of support to be able to do 
that. So families were then troubled and became desperate. We 
heard from several families who were so desperate they would go 
to every single window around the nursing home and just start 
knocking until they found someone that they could talk to to 
wheel their loved one to the window. And they would call us 
just in frustration.
    Some nursing facilities do not have strong broadband 
connection, or lack Internet access. That is also a problem 
that needs to be addressed.
    And so, the extent to which we can require nursing homes to 
provide virtual visitation in lieu of in-person visitation when 
that cannot happen, that should be done.
    Senator Daines. Thank you. I see I am out of time.
    Thank you, Senator.
    Senator Crapo. Thank you, Senator.
    Senator Warner?
    Senator Warren. Was that Senator Warren or Senator Warner?
    Senator Crapo. Warner.
    Senator Warren. Oh.
    Senator Crapo. I am sorry. Wait your turn. [Laughter.]
    Senator Warren. Sorry, Mark.
    Senator Warner. Thank you, Senator Crapo.
    I want to--I have a couple of questions here. One, I want 
to start on the question of nursing home staffing. This is an 
issue I have been working on with Senator Tim Scott. We have to 
make sure--and obviously COVID has shown the ability of the 
facilities to recruit and retain quality staff is a challenge. 
It is oftentimes low pay. Part of that is due to the 
reimbursement rates, meaning the margins are quite thin for 
these facilities. And obviously post-COVID, I think this 
problem was only exacerbated.
    I am going to start with Ms. Ramos. As a nursing home 
worker, could you talk a little bit about this issue and give 
any advice you might have on how we can better recruit and 
retain nursing home workers? And, Dr. Gifford, from the 
Association's standpoint, can you speak to this issue as well?
    Ms. Ramos. Hi; thank you for your question.
    So like I said before, the quality of care and the short 
staffing had been issues before the pandemic. So the pandemic 
made things worse. For us health-care workers in the nursing 
home, it is a big challenge. Most of the time, we have 13 CNAs 
to 12 residents who are total care. So when you have that 
amount of residents per CNA, a lot of them stay in bed for long 
periods of time. And when the family members were coming in to 
visit, they were getting very upset, because they would come at 
10:30 a.m. and their loved ones were in bed. So they would 
complain.
    But as the pandemic hit, we were still working short, and 
as things got worse, we were lucky that we had a union that 
backed us up. And then we have complained for the ones who 
cannot speak for themselves, like our patients in the 
Alzheimer's unit. Our union supports us to speak up for them.
    So with the pandemic, things got worse. And it is worse in 
the nursing home. We are still working short-staffed all the 
time, and our residents are not getting the quality care they 
deserve.
    Senator Warner. Dr. Gifford, did you have a comment?
    Dr. Gifford. Yes. I think, as you heard from all the 
panelists today, the workforce needs to be improved. And we 
need better ways to recruit and retain. I think you have heard 
from us all today that, as you recognized, the tone of this is 
due to the underlying funding.
    You know, the other challenge is, how do we recruit and 
retain beyond just the salaries? I think loan forgiveness 
programs are something we have been championing and we really 
need help with. That would go right to the workers. Tax credits 
for people who work in this sector. Subsidies to schools and 
technical schools to have their graduates working in long-term 
care.
    What we have seen in many of those programs is students get 
sucked up by the hospitals and work elsewhere, and they do not 
come to work in long-term care. So we need to have specific 
programs that make us a priority. I mean, I think the one 
biggest lesson learned from this--and you heard it from 
everyone--is we were not a priority. So if we are going to make 
staffing a priority, we have to make loan forgiveness, tax 
credits, incentives to schools, a priority to get workers into 
long-term care. Otherwise, they will work in the other sectors. 
Thank you.
    Senator Warner. And let me just add, I stand with, I think, 
all our colleagues in a bipartisan way that we need to weed out 
the bad actors in this space. The star rating, I think, has had 
mixed success. But I also know from just a business 
perspective, the reimbursement rates are so low, and the 
margins are so thin, that those nursing homes that are trying 
to do the right thing--and I am particularly concerned now when 
we have seen nursing home populations, perhaps appropriately 
after COVID and people's concerns, fall 20, 25, 30 percent. I 
am not sure what the business model is going to look like, 
particularly in rural communities, so we can keep these 
facilities open with a level of quality where folks like Ms. 
Ramos can have adequate staffing.
    Dr. Konetzka, could you--I know you have done a lot of 
research on this, including reimbursement rates. How can we 
make sure that the good operators are still able to operate, 
and how are we going to grapple with this issue of, in rural 
communities, 20-, 25-percent decrease in patient population? 
What is the model that is going to make this work?
    Dr. Konetzka. That is an excellent question, but it is a 
really hard one. This is the hard challenge to answer, right? 
Because it is almost definitely going to take resources. I 
think we generally underfund long-term care in this country. I 
agree with you that Medicaid rates in many States are very low, 
probably too low to take care of the level of need in a nursing 
home population.
    I think, moving forward, we have to think about fundamental 
changes to the system. I think that there is an aging capital 
stock of nursing homes. There is financial fallout from the 
pandemic. And there are chronic problems such as under-
staffing.
    So I think we need to take a hard look at the underlying 
payment mechanism and the funding we inject into the system, 
and perhaps consider some bold changes.
    Senator Warner. Thank you, Mr. Chairman. I know Elizabeth 
is, I think, next----
    Senator Crapo. Unfortunately, Senator Thune came back. So 
it is going to be Senator Thune next. Elizabeth, we are getting 
there.
    Senator Thune?
    Senator Warner. Famous last words there. [Laughter.]
    Senator Thune. Thank you, Mr. Chairman. Let me just say 
that the subject of today's hearing is one that I think we all 
wish we were not having to discuss, with the stories in our 
States----
    [Loss of audio.]
    Senator Crapo. Senator Thune, have you been muted?
    Senator Thune. Am I on? Hello?
    Senator Crapo. Hello; we can hear you now.
    Senator Thune. Can you hear me now?
    Senator Crapo. Yes.
    Senator Thune. You have me? Okay. All right. Well, I will 
skip the preamble there----
    [Loss of audio.]
    Senator Crapo. John, I think we are having trouble with 
your signal. We will give it about another 5 or 10 seconds, and 
then, Elizabeth, I think I am going to have to--oh, here he 
comes. Can you speak, John, and tell us if you can hear us?
    [No response.]
    Senator Crapo. All right, Elizabeth, why don't you go?
    Senator Warren. All right; thank you, Mr. Chair. And I am 
sorry, Senator Thune, but I am sure we will get this 
straightened out.
    When the coronavirus hit, nursing homes were ground zero. 
Today, at least 34,000 nursing home residents and 1,600 staff 
members have died of COVID-19. Responding to coronavirus is 
challenging for every health-care provider.
    Genesis HealthCare, a nursing home chain with over 350 
facilities across the country, was one provider that struggled.
    Ms. Ramos, you work at Greenville Nursing Center, a Rhode 
Island nursing home owned by Genesis. From your testimony, it 
sounds like working at a facility last year was harrowing. Let 
me just ask: did you have the resources and the staff you 
needed to properly care for COVID-19 patients?
    Ms. Ramos. Thank you for your question. No, we did not have 
enough resources or the staff that we needed. But those, like I 
said before, are not new issues. Sometimes we have two 
residents with serious needs at the same time, but we have to 
choose who deserves our care. And every one of them deserves 
our care, 100 percent. But it is sad that we have been put in 
that situation all the time.
    Senator Warren. And you are right: it is sad to be put in 
that situation. But basically what you are saying is that you 
did not have the supplies, you did not have the staff you 
needed when the coronavirus hit. And I know that a lot of the 
nursing homes around the country were in the same boat, which 
is why Congress passed COVID-19 relief packages like the CARES 
Act earlier to get providers the resources they needed.
    Now in January, I wrote to Genesis, which owns the nursing 
home where you work, and I received information that shows that 
they accepted $665 million in State and Federal grants and 
loans last year. And guess what Genesis did? It gave its then-
CEO an approximately $2-million retention bonus just a few 
months before he left the company, which was and is in dire 
financial condition. In total, the CEO, George Hager, has 
received $8 million in compensation since January of 2020.
    Ms. Ramos, you told us about how one of your co-workers 
died while trying to care for COVID-19 patients, while working 
at a facility with a $14 an hour starting wage. So let me just 
ask you your view on this. Should a top corporate executive 
have received a multi-million-dollar bonus while you were 
struggling to keep patients alive and keep yourself alive?
    Or let me ask it another way. What could have been done to 
improve patient care with that $5.2-million retention bonus 
that the CEO received?
    Ms. Ramos. No, I do not think they should make millions of 
dollars in bonuses, because it is Medicare money. That money 
should be going to patient care.
    So with that $5 million that he received, we could have 
paid a higher wage so we could attract more staff.
    Senator Warner. Right. More staff. More PPE. And that is 
exactly what Genesis should have done. It should have invested 
in workers like you.
    So let me ask you, Dr. Gifford--you are here on behalf of 
the American Health Care Association, which represents nursing 
homes. Do you think it is right that nursing home CEOs received 
multi-million-dollar bonuses, while workers like Ms. Ramos 
fought for more PPE, more tests, and more resources?
    [No response.]
    Senator Warren. Dr. Gifford?
    Dr. Gifford. Senator, as a medical director, having worked 
in nursing homes in Rhode Island, I did not have the pleasure 
of working with Ms. Ramos there, but I saw firsthand--as you 
pointed out and Ms. Ramos has--how hard the CNAs work relative 
to everyone else. And they are really the lifeblood of an 
organization.
    I think early on in this pandemic there was not PPE 
worldwide anywhere. And we were hearing from every type of 
facility out there about the need for getting PPE, and getting 
staffing. And we were calling for it. And what was available 
was not prioritized for nursing homes. It was going to 
hospitals and elsewhere. And I think the idea of how we 
prioritize and use that--the PRF funds that came to us were 
lifesaving. Many of the nursing homes out there are small 
family-run nursing homes, second and third generation----
    Senator Warren. So, I am sorry to interrupt, but that was 
not my question. My question was whether or not nursing home 
executives should be paid multi-million-dollar retention 
bonuses, or whether or not those millions of dollars should be 
invested in the resources that are needed to keep staff and 
residents safe and healthy.
    Dr. Gifford. I think that is a good question, to think 
through how compensation is done at all levels and how are we 
going to be able to compete for retaining and recruiting staff 
at all levels throughout the health-care system. And that is 
something that we will need to look at. And I think we are 
fully supportive of transparency regarding how these funds were 
used going forward.
    Senator Warner. Well, I appreciate that you are going to 
look at it, but I just want to be clear on this. We cannot 
allow corporate greed to determine whether or not workers and 
seniors in this country live or die.
    That is why I wrote to Genesis requesting information about 
their financial decisions. And today I am going to release 
their response, which comes in the wake of reports that Genesis 
will soon be under private-equity ownership.
    I will be opening an investigation into for-profit nursing 
homes, including those run by private-equity firms. And the 
next time there is a pandemic, seniors should not be stuck in 
sub-par institutions run by greedy CEOs and vulture firms in 
order to make a quick buck.
    Commerce needs to act now before tragedy strikes again. 
Thank you.
    Thank you, Mr. Chairman.
    Senator Crapo. Thank you. And, Mr. Chairman, I see you are 
back. Senator Thune, I believe, is next.
    The Chairman. I believe that is right.
    Senator Thune?
    Senator Thune. Thank you, Mr. Chairman. Can you hear me 
this time?
    The Chairman. Yes.
    Senator Thune. All right; we are back. Well, I appreciate 
the subject of today's hearing. Obviously it is a huge issue 
during the pandemic with a lot of nursing home residents 
isolated and unable to see their families, and with quality of 
care and staffing issues that this committee has looked at. 
This committee has, before the pandemic, and now more than 
ever, we need to address these issues to ensure that everyone's 
loved ones receive the care that they deserve.
    Dr. Gifford, I understand at this time facilities are not 
required to report to CMS on staff and resident vaccination. Is 
there no CMS mandate or standard? How are your member 
facilities keeping track of vaccination records? And I am 
thinking about this in the context of future follow-up care 
once we know more about the longevity of COVID vaccines, or the 
need for boosters over time. So if you could address that.
    And then, Mr. Dicken, is there anything GAO is recommending 
on reporting vaccinations in nursing facilities?
    Dr. Gifford. Senator Thune, you are correct that currently 
there is no requirement. All the facilities are tracking 
vaccinations rates on their staff and residents internally.
    There is a portal at the Centers for Disease Control called 
NHSN where you can report staff and resident vaccination rates. 
And we have been strongly urging our members to report that. We 
have been urging CMS and other entities to help sort of move 
that along. And we are fully open to transparency and having 
the information revealed out there, just for quality 
improvement purposes, as well as for family and residents.
    We have also set a goal of getting 75 percent of the 
residents vaccinated. And we need that information to see how 
we have achieved that goal. So we are very supportive of that. 
Thank you.
    Senator Thune. Okay.
    Mr. Dicken, is there anything GAO is recommending on 
reporting?
    Mr. Dicken. Yes; thank you, Senator Thune. And certainly 
GAO is continuing to track vaccine distribution, as well as 
efforts to assure that residents and staff and homes are 
offered vaccines, and to what extent that information is 
available and transparent.
    I would note that there are other models in the nursing 
home setting. There is reporting now of vaccinations for flu or 
pneumococcal, and so certainly GAO has continued to track the 
experience in nursing homes in the current environment of 
COVID-19. GAO is continuing to track that and the efforts to 
make sure that there is data available, and that that can be 
made available, including at facility levels.
    Senator Thune. Okay; thank you.
    Dr. Gifford, as we work to solve quality-of-care 
challenges, we also need to be mindful that access remains a 
priority as our population continues to age.
    You testified the nursing home industry projects up to 
1,600 closures in the aftermath of the pandemic. I expect 
census declines and COVID-related costs contributed to this. 
Could you shed further light on the causes of these closures, 
and if you can, project where in the Nation we might be at risk 
for closure? And of course, I am thinking particularly where I 
come from, like rural areas.
    Dr. Gifford. Senator Thune, I think you are going to see 
the challenges, because the census in the facilities has 
dropped precipitously, from a little over 80 percent to under 
70 percent. It has been about a 15-percent drop. That is not 
sustainable.
    And so I think, particularly in the rural areas and their 
smaller facilities, they are more at risk. I think in States--
which Dr. Konetzka has testified to--with poor Medicaid rates, 
particularly some of the inner city facilities where they have 
a large proportion of Medicaid, they are also at higher risk 
because they do not have the same resiliency to sort through 
this.
    I think if we are going to make nursing homes a priority to 
avoid this and increase the staffing and make the PPE available 
that we need, it is going to have to come through, as Dr. 
Konetzka said, sort of a serious look at, what are the 
investments we are going to make? And how are we going to make 
this a priority going forward? Otherwise, I think in rural 
areas, like in your State, you will see closures. It is just 
not sustainable.
    Senator Thune. On the staffing issue, everybody on the 
panel has mentioned those challenges. I have heard that from 
facilities in South Dakota for years. Recognizing that Federal 
dollars are not unlimited, what solutions should policy-makers 
focus on to have the most immediate and positive impact when it 
comes to workforce staffing?
    Anybody? And I know my time is expiring, so----
    Ms. Moten. I think we need to be creative in terms of how 
we look at staffing, right? I will take the lead from both 
California and Florida, which have programs by which people 
graduating from social work, public health nursing, and one 
other program are required to participate in programs where 
they are going into these facilities.
    So again, we should give them that infection control and 
universal health precaution education, and start looking at 
models with intergenerational aspects. And these are just very 
simple things logistically that we can do, especially as it 
pertains to our rural communities. Because we are going to 
start to see, as Dr. Gifford said, a lot of issues out in those 
rural communities where we have seen bed size compared to 
census drop drastically.
    Senator Thune. Thank you. Thank you, Mr. Chairman.
    The Chairman. All right; thank you, Senator Thune.
    Senator Hassan?
    Senator Hassan. Well, thank you so much, Chairman Wyden and 
Ranking Member Crapo, for the hearing. And I really appreciate 
all of the witnesses being here today. And I know it has been a 
long hearing, so thank you so much to you all for your 
testimony and your work.
    Dr. Gifford, I want to start with a question for you. The 
COVID-19 pandemic has killed more than 174,000 long-term care 
residents over the past year. More than 70 percent of all the 
COVID-19 deaths in my home State of New Hampshire have occurred 
in long-term care settings.
    This pandemic exposed clear failures within these 
facilities, and in the oversight of these facilities. The 
failure to protect this vulnerable population during the 
pandemic is a national tragedy.
    There are many reasons that this happened, and you have all 
discussed a number of them this morning, including the previous 
administration's failure to quickly and adequately respond, 
leaving nursing home workers and residents more vulnerable. But 
nursing homes themselves also need to take a hard look at their 
own role, and take responsibility for their failures.
    So, Dr. Gifford, do you agree that nursing homes bear some 
of the blame for the tragic loss of life we have seen over the 
past year? And assuming that you do, what is the most important 
thing that went wrong? And what is happening now to correct it 
during this crisis and into the future?
    Dr. Gifford. You know, I think you have heard from all of 
us that this pandemic exacerbated some underlying challenges 
that existed in the facilities, particularly around the 
staffing issues. But it also, I think, exposed the fact that we 
lacked a priority. We have seen in previous hurricanes and 
other disasters that the resources go to hospitals and other 
areas, and nursing homes are not a priority.
    The other thing is, there was just a failure to learn over 
time what were the right things to do so we could get rapid 
lessons learned out there. So even, as Dr. Konetzka said, doing 
all the right things at the time would not have worked, because 
they were wrong for this virus.
    I think how we learn from each other--we need to do that. 
We still do not know what the right frequency of testing is. We 
do not know whether opening up for family members to come in is 
going to be the right thing to do, and how to do it.
    Those are critical things that we need to know going 
forward.
    Senator Hassan. But, Doctor--I am going to interrupt you, 
just because my time is limited. What have you learned that you 
can change? What could you do differently? Is it staffing that 
you need to really focus on?
    Dr. Gifford. Well, I think we have taken a hard look at 
that, and I think we agree that we need to have 24-hour R.N. 
staffing, knowing R.N.s in a facility are really key to 
infection control. I have talked before about the infection 
preventions that are necessary. And we think you need to 
stockpile PPE for a 30-day supply. And we support that.
    Senator Hassan. Okay; so thank you.
    I want to move to another issue, because I am sure that you 
saw the recent New York Times reporting on the failures of the 
Federal rating system for long-term care facilities, and its 
reliance on self-reported data.
    There appears to be a widespread practice of inflating the 
number of reported staff responsible for patient care by 
including administrators, some who may not physically work in 
the facility. Staff shortages, as all the testimony has 
established today, have been a major issue during this 
pandemic. And not surprisingly, research suggests that better-
staffed facilities lost fewer patients to COVID-19.
    So, Dr. Gifford, given the disturbing record of some homes 
manipulating data and the importance of adequate staffing, does 
the Federal Government need to increase inspections and end the 
reliance on self-reporting?
    Dr. Gifford. So, Senator, I think--a couple of things on 
the reporting system. There is this perception of self-
reporting. I mean, it is composed of data from the surveyors, 
but that is not self-
reported. The staffing data is from payroll data, which is 
auditable. And certainly we encourage people to follow the 
rules on that issue.
    CMS has identified that there are many directors of nursing 
or nursing supervisors who have spent some time 
administratively and some time providing patient care. Some of 
that administrative time is calling families, so that is why 
they are counted in that program there.
    So I want to make sure you understand what the process is 
there.
    Senator Hassan. I thank you for that. I am going to move on 
to a different issue. But as someone who has worked in a 
nursing home, I understand distinctly the difference between 
being on the phone to families and being at the bedside.
    I want to turn quickly to Ms. Ramos before my time runs 
out, because even with vaccine supply increasing, reports 
suggest that about half of long-term care facility workers 
remain hesitant to take the vaccine.
    And I am wondering, Ms. Ramos, how do you see access to 
paid sick leave impacting the willingness of front-line workers 
to take the vaccine?
    Ms. Ramos. Thank you for your question. I think that has a 
lot to do with it for workers, not only in health care, but in 
general. A lot of people are hesitant to take a vaccine because 
they know that there are side effects. And if they take a 
vaccine and they get sick, they are afraid that there will be 
consequences to pay, like they would use their sick time to pay 
them when they are going to need sick time when their family 
are sick. Or they will use education time, and when they want 
to spend time with their kids, they won't have it because they 
used that.
    Or like for us health-care workers, we work every other 
weekend. So if we take a vaccine on a Friday, and on the 
weekend we get sick and we have to call out, we have to make it 
up the following weekend when we already have plans to spend it 
with our family.
    So I think it should be a system where you do not tell the 
companies to offer it, but it would be a law, like a mandate, 
so it would be better that way than just telling them to offer 
this and to offer that, because they will not follow up.
    Senator Hassan. Thank you very much. And thank you, Mr. 
Chair, for allowing me to go over time.
    The Chairman. Thank you, Senator Hassan. And we are moving 
towards wrapping up, but there are a couple of areas I want to 
get into, because I think we may have missed them.
    A question for you, Ms. Bottcher and Dr. Konetzka. My 
understanding is that CMS has not required that vaccination 
data be made available per facility. Now we are not talking 
about every single person's status; we are talking about the 
aggregate data on, say, this facility, X percentage have been 
vaccinated; this facility, Y percentage have been vaccinated.
    That strikes me as important. What do you two think?
    Ms. Bottcher. Senator, I think it is incredibly important. 
And in fact I spoke to one of our members yesterday, Mark 
Ferguson in Lake Charles, LA, and I posed the same question to 
him: how important is it that you know about the vaccination 
rate at your brother's facility? And he said it was extremely 
important. And in particular, although his brother has been 
vaccinated, it is important that we look to the future. And if 
they need a booster shot, or infection rates start climbing, he 
wants to know that information about his brother's facility.
    The Chairman. All right.
    Dr. Konetzka?
    Dr. Konetzka. I agree. I will just add that, yes, we 
certainly need that information to be public for consumers. 
They have a right to know the vaccination rates in our 
facilities they might be considering. It is also essential for 
researchers and for public health officials to have that data 
to track vaccination rates, to figure out what is working and 
what is not working, and whether vaccination is proceeding with 
equity.
    So I think there is no excuse that those data are not made 
available publicly yet.
    The Chairman. Good. And the last question I think on my 
end, and then I want to kind of sum up where we are: Dr. 
Konetzka, do you have any additional recommendations--I had to 
be on the floor voting for a bit--with respect to what can be 
done to deal with these yawning racial disparities, these 
enormous racial disparities? To some extent, they mirror 
society, as I touched on earlier, but to some extent they seem 
to be even more entrenched, and it is going to take more 
careful efforts to root them out. Do you have any final 
thoughts with respect to racial disparities in nursing homes?
    Dr. Konetzka. Yes, it is an incredibly important issue. So, 
as I said, I think we know that racial and ethnic disparities 
have been prominent in the pandemic, not only generally but 
also in nursing homes. At the same time, long before the 
pandemic, people of color tended to be in lower-quality nursing 
homes. And those nursing homes have a higher Medicaid census. 
Those nursing homes tend to have lower staffing ratios.
    I think in the short run--and this goes back to your data 
question--in the short run, what we need is data on 
vaccinations to make sure that we are reaching their 
communities, the communities of color, but also the nursing 
homes within them, and that we are getting people vaccinated in 
those areas. We need to make sure that strike teams are also 
reaching those larger facilities in lower-income neighborhoods.
    The long-run problem is harder, again because, as you said, 
it sort of reflects residential segregation and the problems 
that go along with the wider disparities in the health-care 
system. But in the short run, we can certainly target 
communities of color to try to reduce those disparities.
    The Chairman. All of you have been a terrific panel, and as 
you can see, my colleagues kept coming back to these important 
points.
    Dr. Konetzka, as you know, I think almost 3 hours ago I 
asked you about private equity, and the fact that they seemed 
to be bringing a ``make money first, and patients somewhere 
later will be discussed'' kind of philosophy, and colleagues 
kept talking about it all through the hearing.
    So we thank you for that. And I could literally go person 
by person and mention your contributions. But I want to close--
--
    Senator Whitehouse. Mr. Chairman, I am back now--Senator 
Whitehouse.
    The Chairman. Okay. Would you like to ask anything else? Or 
do you want to make----
    Senator Whitehouse. If I could drop in one question to Ms. 
Ramos----
    The Chairman. Good. And then I will close it out. Go ahead.
    Senator Whitehouse. Ms. Ramos, when I introduced you, I 
described the amazing tragedy that you lived through with all 
of the fatalities at the Greenville Nursing Center, including a 
colleague, yourself getting the illness, the four of you having 
to try to manage--what was it?--two dozen COVID patients.
    Could you just put as much of a personal experience before 
us of what this all felt like for you and your colleagues 
working in the Greenville Nursing Center, and what you have 
heard from other colleagues who have been doing the same work 
in our nursing homes?
    Ms. Ramos. Thank you for your question. So before COVID, we 
were going through those issues, and we had been fighting at 
the State level to pass the safe staffing, as you know, because 
it had been years and years that we had been working under-
staffed, and the quality of care for our residents was getting 
worse and worse, and the pandemic made it even worse.
    So in those times, I remember when our first unit got 
COVID. We were not allowed to visit our patients. We normally 
would take up a shift in those units because we had known them 
forever.
    Senator Whitehouse. You know them well. I mean, they are 
people in your life, right, the patients?
    Ms. Ramos. Yes. They are like a family to us. So a lot of--
we kept texting our co-workers in that unit and encouraging 
them, and they kept telling us what was going on in that unit. 
If it was a normal day, we know that if somebody was dying, we 
could have stayed over after our shift and spent time with 
those residents, but because they were a COVID unit, we could 
not go there.
    And we felt guilty when we heard such-and-such passed away 
and we could not be there. Their family could not be there for 
them. It was heartbreaking.
    And then when it came to my unit, which is the Dementia 
unit, it was horrible. Like I said before in my opening 
statement, we were working short. There were 26 residents who 
were very ill, and the other CNA and I and a nurse and a 
housekeeper.
    The nurse was overwhelmed. She have a lot to do. And she 
could not help us, and we could not help her. So we had to do 
the best we could. I remember my resident telling me she was 
scared. And I kept telling her, ``It's okay.'' And then she was 
like, ``No, can you stay with me?'' And I couldn't stay with 
her to hold her hand. And I held her hand for a few seconds, 
and then I told her I had to go because somebody else needed 
me.
    And she looked at me with a sad face, and she didn't want 
me to leave. And her family couldn't come in to hold her hand. 
And then I remember, that day a resident passed away. And then 
the funeral home couldn't come in to get the resident. They 
normally, on a regular day, before the pandemic, they came in 
and picked up the resident and we walked away once we put the 
resident in the bag, and we walked out the resident.
    So our job was a resident passing away, and we had to--it 
was the hardest part--we had to put the resident in a bag, in a 
body bag. And those other residents, they are like a family, 
and we love them. So imagine if it's your own family who passed 
away at home and you have to put them in a body bag. And then 
we had to bring them outside.
    So it was horrifying. We worked short all the time, and I 
am glad that we have a union that has our back. We made 
complaints, and the union did what they had to do. And then 
finally we got agency staff who came in to help us.
    But the thing is, management were not there to help us. 
Like when we need help, we ask for help from management. If I 
am a CNA and a nurse, and another CNA is feeding a resident 
because that resident can't feed herself, then we call for help 
to come feed. They don't come to the floor. Another resident 
asked me, ``I need to go to the bathroom.''
    So I have to make a choice right there and then. I have to 
leave that resident with the tray in front of them--that 
resident can't feed themselves--and take the other resident to 
the bathroom. Because with short staff, we don't have another 
staffer who would take over. And those are the choices that we 
had to make day to day before the pandemic, and with the 
pandemic, things got worse.
    It is a sad situation, but I don't think it should just be 
a safe level that we're fighting for. Our union is fighting 
across the country to change the staffing of nursing homes. I 
think you guys have the power and that you can change it and 
have oversight in these nursing homes, and make it better for 
the quality of care for our residents and for our staff. Our 
staff are not leaving the nursing homes because they don't want 
to work in a nursing home; that is not the reason why they are 
leaving the nursing homes. They are leaving the nursing homes 
because the workload is a lot for the nurses and the CNAs. And 
they go work at the hospital where they will get less patients, 
and they pay them more than a nursing home.
    They don't want to leave their residents, but they have to 
look at it with their health too at risk, and they don't want 
to go home exhausted after a long day at work, you know?
    Senator Whitehouse. Well, thank you so much, Ms. Ramos. 
People call you and your colleagues heroes for a reason. You 
are heroes of the heart, and I thank you for being here.
    The Chairman. Ms. Ramos, you have another Senator who, I am 
sure, is very interested in your view as well, and we want to 
hear from her: Catherine Cortez Masto.
    Senator Cortez Masto. Thank you, Mr. Chairman and Ranking 
Member. This has been an incredible conversation.
    Ms. Ramos, I am going to follow up because I truly agree 
with Senator Whitehouse. There are so many heroes on the front 
line right now, including you and so many at the SEIU and the 
work that you are doing.
    My challenge has been--and I am hoping you can help with 
this--and I think the conversation you were having was, how do 
we attract more staff at the long-term care facilities?
    Can you talk a little bit about the benefits and other 
things? What should we be doing? How do we attract them to make 
sure that we are not only getting them into the facilities 
because they are under-staffed, but taking care of them as 
well?
    Ms. Ramos. Thank you for your question. The way that we 
attract them is to put the starting rate higher than it is 
right now. Because nursing homes' starting rate is very low for 
CNAs, and they can go to hospitals and make more, or they can 
work for agencies that are making double what we make.
    So those are the challenges. And also, the staffing. They 
need to change the staffing in the nursing homes. Because if 
someone starts working in a nursing home and they end up having 
12, 13 patients who are total care--they cannot do anything for 
themselves--within 3 months, they leave. And they get the 
experience that they need. They leave the nursing home, and 
they go to work somewhere else because, you know, they're like, 
``I can't do this job, because it's a lot and they don't pay 
enough.''
    So those are the main challenges that we face in the 
nursing homes. And I am grateful that I have a union that 
fights for better wages and better staffing in nursing homes, 
but when you're fighting for it State by State--we want this 
fight to go across the country.
    Senator Cortez Masto. Thank you. Thank you so much, and for 
your advocacy. It is so important.
    Let me jump to, I believe it's Dr. Konetzka. I know there 
has been talk about private equity now being involved with 
long-term care, but can you opine on what sort of guard rails 
Congress should consider to ensure that additional resources 
that flow to long-term care facilities are invested in patient 
care and staff?
    Dr. Konetzka. Yes, it is an important question. And I think 
the first step is transparency. Right now, we just do not know 
where the money is flowing. So you know, we need to make 
reporting of those arrangements mandatory and assess where we 
are and whether current reimbursements are enough, or what else 
we need to invest into the system.
    And then, I think the next step would be to consider some 
more oversight or regulation of these arrangements. When there 
is so much public money involved, I think some accountability 
is warranted. And we should be able to make sure, when we put 
Medicare and Medicaid money into nursing homes, that at least a 
certain proportion of it goes to patient care.
    Senator Cortez Masto. Thank you.
    Again, this conversation today has been so helpful, I think 
to all of us. We so appreciate having this hearing today, Mr. 
Chairman, and I yield back to you.
    The Chairman. I thank my colleague. And I know of her 
advocacy for seniors.
    Here is my take on where things are. This has really been 
the area I have focused on in my time in public service. I was 
director of the Gray Panthers, ran the legal aid office for the 
elderly, and I have long known that, from sea to shining sea, 
there are persons who care deeply about the well-being of those 
patients in nursing homes.
    And, Ms. Ramos, I can tell you--because I have visited with 
a couple of my colleagues when we were voting--you have left 
our members with a very clear call to action. You spelled it 
out: here are the problems, and the buck is not at the State 
level or the local level, or anywhere else; it is in the U.S. 
Congress. And the Senate Finance Committee has jurisdiction 
over this area.
    I so appreciate what you have done. I appreciate all of 
you, and I think if I were to sum it up, despite all of the 
caring, good people who work in a number of nursing homes in 
America, we have still seen in the last year what I describe as 
a collision of mismanagement at every level. And Ms. Ramos 
started it off 3 hours ago when she talked about under-staffing 
and infection. And then she talked about the problems with PPE, 
not even being able to get basic protective equipment. And then 
she described, ``Hey, by the way, we are also kind of in the 
dark. We have had difficulty getting information.''
    So I have had a number of opportunities over the years to 
hear about what needs to be done in terms of long-term care, 
and I think this has been a stellar panel. You have spelled it 
out.
    Ms. Ramos has made it really clear. She is going to hold 
the Congress of the United States accountable. And that is 
exactly what we need. So I want you to know that I guess I am 
calling an end to the hearing for today, but let me tell you 
something. This hearing and the issues that we are going to be 
focused on, because of what you have said today and your call 
to action and accountability, is not something to be swept 
away. This is to be continued.
    I thank you all. Terrific hearing, and I look forward to 
staying in touch.
    Oh, I have one other matter. I would like to thank Ranking 
Member Crapo and all committee members for their participation. 
We thank our witnesses, of course, and for the information of 
all members, questions for the record should be submitted by 5 
p.m. on Wednesday, March 24th. And with that, the hearing is 
adjourned.
    Ms. Ramos. Thank you.
    [Whereupon, at 12:55 p.m., the hearing was concluded.]

                            A P P E N D I X

              Additional Material Submitted for the Record

                              ----------                              


                Prepared Statement of Denise Bottcher, 
                     State Director, AARP Louisiana
    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
thank you for inviting AARP to testify today. My name is Denise 
Bottcher and I am the State director for AARP Louisiana. On behalf of 
our 38 million members, including over 425,000 in Louisiana, and all 
older Americans nationwide, AARP appreciates the opportunity to provide 
testimony at today's hearing. The situation in our nation's nursing 
homes and other long-term care facilities has been alarming since the 
beginning of the pandemic. Since then, AARP has consistently advocated 
for the health, safety and well-being of residents and staff.

    These facilities have been ground zero in the fight against the 
coronavirus, representing a shockingly high share of COVID-19 deaths. 
Over 175,000 long-term care facility residents and staff have died--
including almost 3,000 in Louisiana--due to COVID-19, representing 
about 35 percent of the deaths nationwide and over 30 percent of deaths 
in Louisiana, even though nursing home residents comprise less than one 
percent of the U.S. population.

    These horrifying numbers are a tragedy and national disgrace. AARP 
has heard from thousands of people across the country whose loved 
ones--their mothers, fathers, grandparents, aunts, uncles, and dear 
friends--lost their lives, alone, in nursing homes. We recognize that 
even before the pandemic, many long-term care facilities struggled with 
basic infection control and adequate staffing. And we knew when the 
first COVID outbreak occurred at the Kirkwood facility, that the 
situation in these facilities was dire.

    There were important steps taken, but too often the response was 
too slow and inadequate. Much more was and is needed now, and in the 
future, to protect residents, staff, their loved ones, and the 
surrounding communities from this disease. For the 4-week period ending 
February 14, the rates of COVID-19 cases and deaths in nursing homes 
were still higher than in late summer, according to AARP's Nursing Home 
Dashboard. That is unacceptable. While there may be a sense of relief 
with vaccines rolling out and cases and deaths in long-term care 
facilities finally declining, there are still too many deaths, and 
policy-makers and facilities are not relieved of their responsibility 
to protect nursing home residents. The consequences of not addressing 
the issues such as infection control, staffing, sufficient personal 
protective equipment and testing, oversight, accountability, and not 
following guidance is that someone's dad or mom dies. It is not a could 
act or should act situation, it is a must act situation. During the 
pandemic, AARP has urged action on a five-point plan to slow the spread 
and save lives:

    1.  Ensure facilities have adequate personal protective equipment 
for residents, staff, visitors, and others as needed, and prioritize 
regular and ongoing testing.

    2.  Improve transparency on COVID-19 and demographic data, 
vaccination rates of residents and staff by facility, and 
accountability for taxpayer dollars going to facilities.

    3.  Ensure access to in-person visitation following Federal and 
State guidelines for safety and require continued access to facilitated 
virtual visitation for all residents.

    4.  Ensure quality care for residents through adequate staffing, 
oversight, and in-person access to long-term care ombudsman.

    5.  Reject immunity and hold long-term care facilities accountable 
when they fail to provide proper care to residents.
    ensure access to personal protective equipment (ppe) and testing
    It is critical to provide PPE and ensure its consistent proper use 
by all staff caring for individuals in nursing homes, assisted living 
facilities, other residential care communities, home and community-
based and other settings. PPE must be available for residents, staff, 
visitors, and surveyors.

    Centers for Medicare and Medicaid Services (CMS) testing 
requirements for nursing home residents and staff have been an 
important step. We have strongly supported regular, prioritized testing 
of residents and staff as an important mechanism to prevent COVID-19 
from entering nursing homes and other long-term care facilities, detect 
cases quickly, and stop transmission to additional residents and staff. 
Even with vaccines, we know that PPE and regular testing are still 
needed to stop the spread of coronavirus and other pathogens. AARP 
supports the funding in the American Rescue Plan Act for infection 
control and vaccine uptake support provided by quality improvement 
organizations to skilled nursing facilities. We also note that one of 
the best ways to keep people safe in nursing homes is to send fewer 
people to nursing homes who do not need that level of care.
           ensure transparency on covid-19, demographic, and 
            vaccination data, and use of funds by providers
    AARP has called for increased transparency of COVID-19 cases and 
deaths in long-term care facilities, including demographic data, such 
as race and ethnicity. We appreciated the CMS guidance and interim 
final rule with comment that took steps towards achieving greater 
transparency on COVID-19 cases and deaths and notification to 
residents, their representatives, and families about cases in the 
facility, as well as ensuring nursing homes are better prepared to 
respond to the public health emergency. While these reporting 
requirements are a necessary step, we believe care facilities should 
also report publicly daily whether they have confirmed COVID-19 cases 
and deaths, and that reporting should include demographic data.

    The COVID-19 pandemic has shed light on the stark racial 
disparities affecting health outcomes for communities of color across 
the country. A recent national study found that nursing homes with a 
higher percentage of African American/Black or Hispanic residents had 
more than three times as many COVID-19 deaths as those that had a 
higher percentage of White residents. While there is a growing body of 
data that shows African Americans/Blacks, Hispanics, and American 
Indians and Alaska Natives are disproportionately impacted by the 
pandemic with higher rates of infection and death, more complete racial 
and ethnic data is still needed. Furthermore, there is insufficient 
data to fully demonstrate the impact of COVID-19 on Asian American and 
Pacific Islander (AAPI) communities, but some disaggregated data show 
mortality rates that are disproportionately high in some places.

    To disrupt health disparities across the country, including those 
occurring within nursing homes and other long-term care facilities, we 
need better data. It is important that the Federal Government gather 
data and publicly report on COVID-19 cases, deaths, co-morbidities, and 
testing rates broken down into multiple demographic categories--while 
protecting patient privacy--including race, ethnicity, age, 
socioeconomic status, sexual orientation, gender identity, spoken/
written language and disability. Data should also include venues such 
as hospitals, nursing homes, assisted living facilities, residential 
homes, and other locations. The information, disaggregated for all 
groups, should also be contrasted with 2019 numbers to truly understand 
the impact of COVID-19 on all communities. Collection, analysis, and 
regular public reporting of the detailed disaggregated information will 
help us effectively understand and respond to the crisis in a timely 
and focused way so that we can minimize the spread of the virus and 
improve health outcomes now and into the future. Indeed, given what we 
have learned in this crisis, improved data collection and reporting 
needs to be an ongoing practice for all long-term care facilities.

    In addition, we believe vaccination data also needs to be broken 
down by age, race, and ethnicity for States, the Federal Government, 
and consumers to fully understand where the gaps are in vaccination 
administration. It is of utmost importance that this information be 
updated as quickly as possible, even daily. Furthermore, separate 
information about the number and percentage of residents and staff who 
have been vaccinated should be available by facility and State. While 
vaccines have given us all great hope of returning to normalcy, 
vaccines only work when they have been administered. We are deeply 
concerned about reports that there is a lack of vaccine confidence 
among long-term care staff. Policy-makers at the Federal and State 
level need to urgently focus their attention on this critical 
population to communicate clearly and credibly with these staff about 
the vaccines. Moreover, while the Long-Term Care Partnership with CVS 
and Walgreens was able to provide vaccines to residents and staff who 
wanted them, it is critical that vaccines remain available to new 
residents and staff, or those who initially opted out. We urge the 
Federal Government to work with States and long-term care facilities to 
ensure they can access and administer vaccines as needed.

    We also need greater transparency on how the billions of dollars in 
taxpayer money from the Provider Relief Fund that have gone to 
facilities have been spent. Furthermore, if nursing homes or other 
long-term care facilities receive any additional dollars from the 
Provider Relief Fund or similar funds, AARP strongly urges that the 
administration and Congress ensure that such funding is used 
exclusively for the health, safety, and well-being of residents and 
staff, such as for PPE, testing, staffing, virtual visitation, 
infection control and other items that directly relate to resident care 
and well-being, prevention, and treatment. Facilities should be 
accountable for their use of taxpayer dollars, and funds should 
directly benefit residents.
        ensure safe in-person visitation and require facilities 
              to provide and facilitate virtual visitation
    For many Americans living in nursing homes and other facilities, 
their friends and family provide not only a source of comfort, but also 
an important safety check. In-person visits, with some exceptions, have 
largely been halted over most of the past year.

    We were pleased that CMS provided updated nursing home visitation 
guidance on March 10 that allows easier in-person visitation at nursing 
homes, while continuing to emphasize infection prevention and control 
practices for facilities, visitors, and others. This is very welcome 
news for nursing home residents and families.

    In the year since the pandemic began, we have heard heartbreaking 
stories about the challenges families have had trying to see their 
relatives and the many important moments they missed. As we enter a new 
phase of this pandemic with the ongoing rollout of vaccines and growing 
knowledge about public health needs--including the safety, mental 
health, and social well-being of nursing home residents--it is vital 
that these vulnerable seniors can safely visit with their loved ones. 
Residents must be able to exercise their rights to visitation, and 
facilities should be held accountable for facilitating in-person 
visitation. AARP wrote to CMS on February 23 urging the agency to 
update its guidance, criteria, and support for safe in-person 
visitation.

    While not a replacement for in-person visits, virtual visits can be 
an important lifeline for families, friends, and residents. We have 
urged Congress to require residential care facilities to make available 
and facilitate virtual visitation via videoconference or other 
technologies for residents and their loved ones. We also urge Congress 
to provide funding to support virtual visitation. AARP supports the 
bipartisan Advancing Connectivity during the Coronavirus to Ensure 
Support for Seniors Act (S. 57/H.R. 596), that would provide such 
funding, specifically grants to nursing homes to support virtual 
visits.
    ensure adequate staff, oversight, and access for long-term care 
                               ombudsmen

    We are deeply concerned about staffing shortages at residential 
care facilities. AARP's Nursing Home Dashboard has consistently found 
over 25 percent of nursing homes nationally reporting a shortage of 
direct care workers since June 2020. It is essential that, at a 
minimum, staff/resident levels be maintained despite a potential 
reduction in workforce due to COVID-19 related circumstances. Many 
facilities had inadequate staff prior to the pandemic, and it is 
essential that staff be adequate to meet residents' many COVID- and 
non-COVID-related care needs, including infection control. Across the 
country, we have seen that higher staffing levels are associated with 
fewer deaths and COVID-19 cases in nursing homes. In addition, research 
shows that nursing homes with a registered nurse on staff help improve 
the quality of care. AARP supports funding in the American Rescue Plan 
Act for State strike teams in nursing homes with COVID-19 cases. AARP 
further urges Congress to take action to ensure that staffing levels in 
long-term care facilities are adequate, such as through pay and other 
compensation, paid leave, recruitment, training, and retention.

    It also remains important for residents to have in-person access to 
long-term care ombudsmen, who play an important role in advocating for 
residents and their families.

    More broadly, oversight from CMS and State survey agencies, 
including regular surveys, is vital now more than ever to ensure 
facilities are providing quality care and that resident health, safety, 
well-being, quality of life, and rights are protected. Strong 
enforcement action should be taken, when needed, to protect residents 
and ensure their rights. AARP also supports funding included in the 
American Rescue Plan Act for Elder Justice Act programs.
         reject immunity for nursing homes and other long-term 
               care facilities and hold them accountable
    The pandemic has put residents' health, safety, and quality of care 
at unprecedented risk, as reflected by the horrific death tolls. We 
know that staff in many long-term care facilities are doing heroic 
work, putting their own health on the line to care for people in 
nursing homes. But sadly, AARP has heard from thousands of families 
across the country whose loved ones were not treated with the 
compassion or dignity that every American deserves. AARP strongly urges 
Congress to protect the safety of residents, including by maintaining 
the rights of residents and their families to seek legal redress to 
hold facilities accountable when residents are harmed, neglected, or 
abused.
      support individuals to remain in their homes and communities

    While we work to reform our Nation's long-term care facilities, we 
need to support the ability of people to remain in their homes and 
communities. Not only will this help people to live where they want to 
be, but also help to alleviate some of the challenges we are facing in 
our Nation's nursing homes. Furthermore, on average, for every one 
person residing in a nursing home, Medicaid can fund three individuals 
receiving community-based long-term care.

    Congress must also look longer-term to give older adults and people 
with disabilities more options to live in their homes and communities, 
including more options to receive care at home, and more support for 
family caregivers who help make it possible. A family caregiver tax 
credit, as in the bipartisan, bicameral Credit for Caring Act, would 
help provide some financial relief to eligible family caregivers.

    The pandemic has also highlighted the need to transform nursing 
homes, including by supporting or incentivizing small house nursing 
homes, such as Green Houses with private rooms and an empowered staff, 
making available private rooms, and creating a direct care ratio or 
medical loss ratio for nursing homes to ensure that public funds going 
to these facilities are used for resident care.

    Families across the country are looking to Congress and the 
administration for swift action to protect the health and safety of 
their loved ones living in long-term care facilities now and in the 
future. We cannot wait any longer. Thank you again for your attention 
to this urgent challenge.

                                 ______
                                 
         Questions Submitted for the Record to Denise Bottcher
                 Questions Submitted by Hon. Ron Wyden
    Question. The Centers for Medicare and Medicaid Services (CMS) 
issued an interim final rule last year that required nursing homes to 
report COVID-19 data to the Centers for Disease Control and Prevention 
on a weekly basis beginning May 17, 2020. These data included COVID-19 
infections, COVID-19 deaths, and the availability of key equipment and 
workers at individual nursing homes. The data have proved to be helpful 
for the public, policy-makers, and industry stakeholders to track the 
pandemic, and related issues, in these care settings. However, to date, 
CMS has not required nursing homes to provide such data prior to May 8, 
2020, despite calls from Senate Democrats to do so. In September 2020, 
the Government Accountability Office (GAO) noted that ``by not 
requiring nursing homes to submit data from the first 4 months of 2020, 
HHS is limiting the usefulness of the data in helping to understand the 
effects of COVID-19 in nursing homes.'' GAO went on to recommend that 
``HHS, in consultation with CMS and CDC, develop a strategy to capture 
more complete data on COVID-19 cases and deaths in nursing homes 
retroactively back to January 1, 2020.''

    Do you support GAO's recommendation? Why or why not? Please briefly 
explain.

    Answer. Yes, AARP has supported the collection of data on COVID-19 
cases and deaths in nursing homes retroactively prior to May 8th. 
Without this data, there is an incomplete State and national picture of 
COVID-19's impact on nursing home residents and staff. Given that 
nursing homes were not required to report COVID-19 cases and deaths to 
the Centers for Medicare and Medicaid Services (CMS) until May, the 
numbers of COVID-19 cases and deaths reported by nursing homes are a 
significant undercount before June 2020 in this data source. 
Transparency is important and can help provide learnings to address 
issues and help make sure they do not happen again in the future.

    Question. A recent paper published by the National Bureau of 
Economic Research noted that people who receive treatment in nursing 
homes owned by private equity firms have worse health outcomes than 
those living in facilities under other ownership structurers. This 
paper adds evidence to reports of worse outcomes associated with 
private equity's investment in the nursing home industry. Nursing homes 
have also become popular investments for real estate investment trusts 
(REITs), which often lease back properties to private equity firms or 
other related parties. The involvement of private equity in the nursing 
home industry has been of interest to the Finance Committee for more 
than a decade, and was a topic of interest for members during this 
hearing.

    How would additional ownership transparency benefit families and 
patients as they consider nursing homes for themselves or their loved 
ones?

    Answer. If consumers and their families have information about how 
a particular nursing home's ownership impacts or may impact the quality 
of care or quality of life residents receive in that nursing home, it 
could help them make more informed choices about whether that nursing 
home is appropriate for them and will meet their needs. It is important 
that information for consumers and their families is 
consumer-friendly and easily understandable.

    Question. Section 6101 of the ACA sought to increase transparency 
of nursing home ownership structurers. To date, CMS has not fully 
implemented or enforced this section of the ACA, although the agency 
does have existing reporting mechanisms for nursing home ownership that 
provide a certain amount of information to the public. As the committee 
considers the changing ownership landscape in the nursing home 
industry, would implementing section 6101 provide sufficient 
transparency? Would you suggest additional measures the committee 
should consider?

    Answer. Fully implementing current law is an important step. We 
suggest that the committee seek technical assistance from the Centers 
for Medicare and Medicaid Services and consult with researchers and 
others who have more closely examined private equity ownership to see 
what gaps may remain, and what additional measures may be needed to 
capture relevant data and information that may be important to families 
and the general public.

    Question. COVID-19's toll on nursing homes has not been limited to 
viral infections. Residents have suffered mentally and physically, and 
had less access to family members and patient advocates. On March 10, 
2021, the Centers for Medicare and Medicaid Services issued new 
guidance that allows for residents to more easily receive visitors. On 
the same day, the Centers for Disease Control and Prevention issued 
Updated Healthcare Infection Prevention and Control Recommendations in 
Response to COVID-19, which stated ``quarantine is no longer 
recommended for residents who are being admitted to a post-acute care 
facility if they are fully vaccinated and have not had prolonged close 
contact with someone with SARS-coV-2 infection in the prior 14 days.'' 
The committee has received written testimony for this hearing from 
medical experts raising concerns that the new guidance may be overly 
permissive, and could put nursing home residents in danger, 
particularly if COVID-19 variants breakthrough vaccine protections. On 
the other hand, some advocates have called for more permissive 
visitation guidelines.

    Do you view the guidance as properly balanced? Do you think there 
needs to be adjustments to protect the safety of residents and workers?

    Answer. Throughout the pandemic, scientists across the globe have 
worked hard to better understand this virus and the disease it causes. 
We appreciate that as the science has progressed, the Centers for 
Medicare and Medicaid Services (CMS) and the Centers for Disease 
Control and Prevention (CDC) have adapted their ongoing guidance 
related to nursing homes. Informed learnings about public health 
needs--including the physical safety, mental health, and social well-
being of nursing home residents--and ongoing vigilance to ensure these 
things is vital, especially given the impact of COVID-19 on nursing 
home residents and staff. Continued learnings, assessment, and 
information based on science, should inform guidance from CMS and CDC, 
which is important on these issues and will continue to be going 
forward.

    Question. Preliminary research conducted by Columbia University 
researchers suggests that the Pfizer and Moderna vaccines were up to 12 
times less effective at neutralizing the B.1.351 COVID-19 variant 
(``South African variant'') than earlier strains of the coronavirus.\1\ 
The researchers also found that convalescent plasma was 9 times less 
effective against the South African variants, leading them to write 
``[t]aken together, the overall findings are worrisome, particularly in 
light of recent reports that both Novavax and Johnson & Johnson 
vaccines showed a substantial drop in efficacy in South Africa.''\2\ 
The researchers went on to write, ``mutationally, this virus is 
traveling in a direction that could ultimately lead to escape from our 
current therapeutic and prophylactic interventions directed to the 
viral spike. If the rampant spread of the virus continues and more 
critical mutations accumulate, then we may be condemned to chasing 
after the evolving SARS-CoV-2 continually, as we have long done for 
influenza virus.''\3\ The Centers for Disease Control and Prevention 
(CDC) has previously found suspected cases of reinfection among nursing 
home residents who previously tested positive for COVID-19.\4\ 
Similarly, a paper published earlier this year in The Lancet suggested 
that a resurgence in COVID-19 cases in the Brazilian city of Manaus may 
have been due to a new variant (known as P1 or ``Brazilian variant'') 
``may evade immunity generated in response to previous infections.''\5\
---------------------------------------------------------------------------
    \1\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
    \2\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
    \3\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
    \4\ https://www.cdc.gov/mmwr/volumes/70/wr/mm7008a3.htm.
    \5\ https://www.thelancet.com/article/S0140-6736(21)00183-5/
fulltext.

    The South African and Brazilian variants continue to circulate in 
the United States.\6\ What is your level of concern about the danger 
that these and other COVID-19 variants may pose to nursing homes, 
particularly residents who have been most vulnerable to the disease?
---------------------------------------------------------------------------
    \6\ https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant-
cases.html.

    Answer. While vaccines give us all great hope of returning to 
normalcy and we have seen declines in facility cases and deaths, given 
the impact of COVID-19 on residents and staff, continued vigilance is 
needed to ensure their health, safety, and well-being, including access 
to sufficient personal protective equipment (PPE) and testing. More 
than 182,000 residents and staff of nursing homes and other long-term 
care facilities have died due to COVID-19, representing about one-third 
of all COVID-19 deaths nationwide to date. These horrifying numbers are 
a tragedy and national disgrace, and we must take every precaution to 
---------------------------------------------------------------------------
prevent any further outbreaks.

    Throughout the pandemic, scientists across the globe have worked 
hard to better understand this virus and the disease it causes. We 
appreciate that as the science has progressed, the Centers for Medicare 
and Medicaid Services (CMS) and the Centers for Disease Control and 
Prevention (CDC) have adapted their ongoing guidance related to nursing 
homes. Continued learnings and guidance from CMS and CDC will be 
important going forward.

    Question. Is additional surveillance necessary to detect the spread 
of viral variants? What types of surveillance, if any, should be 
implemented in regards to the nursing home industry specifically?

    Answer. Ongoing and improved public health surveillance related to 
COVID-19 and variants is important to understand how they are impacting 
individuals and the population overall. The Centers for Disease Control 
and Prevention (CDC) and Centers for Medicare and Medicaid Services 
(CMS) should work together to determine what types of additional 
surveillance, if any, should be implemented in relation to the nursing 
home industry. AARP has urged greater transparency around COVID-19 and 
nursing homes, including on COVID-19 cases and deaths, demographic 
data, and vaccination rates of residents and staff by facility. If 
there is additional surveillance, timely information should be shared 
with the public, residents, families, and staff.

    Question. In the event that additional vaccinations and/or booster 
shots are needed to protect against variants, do you have a view on 
what would be the best model to accomplish such a rollout, and what 
would be a reasonable amount of time?

    Answer. We would encourage looking at the successes, experiences, 
and lessons learned from the Pharmacy Partnership for Long-Term Care 
Program and other State experiences with vaccinations in long-term care 
facilities. Using a model informed by those experiences, and perhaps 
similar to the Partnership, would be a good place to start. Timing 
should be informed by that previous experience and the protocol for 
additional vaccinations and/or booster shots, but once such 
vaccinations or booster shots are available they should be administered 
as effectively, efficiently, and quickly as possible. Given the risk to 
older populations, nursing home and other long-term care facility 
residents and older Americans should be prioritized. There should also 
be a clear plan from the beginning to ensure ongoing access to 
additional vaccinations and/or booster shots for residents and staff 
after the initial rollout.

    Question. What lessons can be drawn from the experience of the CVS-
Walgreen Long-Term Care Partnership in regards to additional 
vaccination campaigns?

    Answer. It is important to learn from what worked well in terms of 
the successful vaccination of residents and staff, as well as other 
lessons including the importance of educating residents, staff, and 
families about the vaccine and building vaccine confidence, especially 
among staff; having multiple ways to get consent for vaccination; 
ensuring sufficient vaccine supply and addressing initial distribution 
problems; improved allocation of the number of needed doses; and having 
a clear plan from the beginning to ensure ongoing access to additional 
vaccinations and/or booster shots for residents and staff after the 
initial rollout.

                                 ______
                                 
              Question Submitted by Hon. Patrick J. Toomey
    Question. Prior to the COVID-19 pandemic, I worked alongside my 
Pennsylvania colleague Senator Casey to address the quality of care for 
nursing homes residents. We were successful in pressing the Centers for 
Medicare and Medicaid Services (CMS) to publicize both participants and 
candidates affiliated with the Special Focus Facility (SFF) program, 
which provides more frequent oversight of facilities that consistently 
fail to meet Federal safety and care requirements.

    Specific to this issue, Senator Casey and I reintroduced the 
Nursing Home Reform Modernization Act (S. 782) on March 16, 2021, which 
would expand the SFF program to ensure that all facilities nominated as 
candidates for the program receive additional oversight. Our 
legislation would also increase educational resources for 
underperforming facilities and create an independent advisory panel to 
inform CMS on how best to rank nursing home performance.

    AARP has been instrumental in crafting our legislation and has 
endorsed the bill. Can you discuss the impact this legislation will 
have on nursing home residents?

    Answer. AARP appreciates the bipartisan work that you and Senator 
Casey put into the Nursing Home Reform Modernization Act. Importantly, 
as you note, your bill would expand the number of nursing homes in the 
Special Focus Facility (SFF) Program to identify and increase 
transparency around those facilities with a history of serious quality 
issues and ensure they receive more frequent inspections. Inspections 
can help identify important quality of care issues or problems that 
must be addressed by a facility to ensure resident health and safety.

    The legislation also includes vital consumer protections to help 
ensure appropriate oversight and accountability for nursing homes and 
requires consumer participation in an Advisory Council examining 
processes for ranking nursing homes prior to the establishment of such 
a ranking system. It is important for consumers to have representation 
on this Advisory Council, so that their voices and experiences help 
inform the Council's work.

                                 ______
                                 
                Question Submitted by Hon. John Barrasso
    Question. A top concern of Wyoming nursing facilities is making 
sure there are enough staff to care for residents.

    Many Wyoming nursing homes provide professional development and 
other educational opportunities to attract and maintain their staff.

    Can you discuss solutions related to workforce development you 
believe will improve the ability of nursing facilities to attract and 
maintain direct care staff?

    Answer. COVID-19 exacerbated existing direct care staff shortages 
that pre-dated the pandemic. It is essential that, at a minimum, staff/
resident levels be maintained despite a potential reduction in 
workforce due to COVID-19 related circumstances. Across the country, we 
have seen that higher staffing levels are associated with fewer deaths 
and COVID-19 cases in nursing homes. In addition, research shows that 
nursing homes with a registered nurse on staff help improve the quality 
of care. AARP supported funding in recently enacted legislation for 
State strike teams in nursing homes with COVID-19 cases. This would 
help provide additional support to facilities when they need it most. 
AARP has further urged Congress to act to ensure that staffing levels 
in long-term care facilities are adequate, such as through pay and 
other compensation, paid leave, recruitment, training, and retention.

                                 ______
                                 
                 Questions Submitted by Hon. Todd Young
    Question. As outlined in many of your testimonies, the visiting 
restrictions and isolation necessitated by the COVID-19 pandemic took a 
heavy toll on the emotional and mental health of many nursing home 
residents separated from their family members and other loved ones. 
Fortunately, with increased vaccination and declining COVID-19 deaths, 
many of these restrictions have been lifted.

    While we hope that restrictions of this scale will not be necessary 
again, it is worth examining ways to alleviate the negative emotional 
and mental health effects that isolation may have on nursing home 
residents. The use of technology, for one, has allowed residents to 
interact virtually with family and other loved ones from whom they are 
otherwise separated. Expanded use of telehealth has also helped 
residents access routine health-care services while limiting spread of 
the coronavirus.

    What are some lessons learned from the public health emergency in 
terms of the integration of technology in nursing homes--both in 
helping residents visit virtually with loved ones and in accessing 
health-care services?

    Answer. The COVID-19 pandemic increased the use of technology in 
nursing homes for virtual visits with loved ones and accessing health-
care services through telehealth. While not a replacement for in-person 
visits, virtual visits can be an important lifeline for families, 
friends, and residents both as a source of comfort and an important 
safety check. Access to these visits is important. Among the lessons 
learned are the importance of access to the necessary technology, 
including videoconference or similar technology to enable residents to 
see their family and friends, and funding for it; designated staff to 
facilitate virtual visits with residents (including assisting with the 
use of the technology and scheduling visits); regular cleaning and 
disinfecting of devices; and the availability of broadband access to 
use the technology. It is also important for facilities to communicate 
clearly with residents and families about how to access virtual visits.

    The use of telehealth in nursing homes during the pandemic has 
helped ensure more efficient and effective access to health care. 
Telehealth is an effective way to deliver care while preserving 
physical distancing and minimizing risk of COVID-19 exposure. In 
addition, telehealth may enable the participation of family caregivers 
in the visit with the consent of the resident. This could help with 
care coordination, care continuity, a smooth discharge from a skilled 
nursing facility, and care at home post-discharge. AARP has supported 
greater access to telehealth for Medicare beneficiaries, and CMS has 
made many temporary changes to increase telehealth access during the 
public health emergency. Data from these temporary administrative 
policy changes should be examined before they are made permanent by 
congressional action. Specifically, individual telehealth services 
should be reviewed for their impact on quality of care and disparities. 
We would also encourage policy-makers to fully update and enforce the 
Health Insurance Portability and Accountability Act (HIPAA)--to reflect 
changes in technology and utilization--alongside making permanent 
policy changes. We also note that the use of telehealth is a tool meant 
to supplement, not replace, necessary in-person care.

    Question. How do you anticipate this type of technology continuing 
to be used beyond the pandemic?

    Answer. Beyond the pandemic, virtual visits can enable residents to 
visit with loved ones who may be unable to visit in person for a 
variety of reasons, including but not limited to distance or illness. 
Virtual visits can also be helpful and important if a resident is sick 
or not feeling well, to enable a larger group of individuals to visit 
with a resident, and to enable family and friends to check in on their 
loved ones. Technology can also help enable the participation of family 
caregivers--with the consent of the resident--to assist with care 
coordination, care continuity, a smooth discharge from a skilled 
nursing facility, and care at home post-discharge.

                                 ______
                                 
       Submitted by Hon. Sherrod Brown, a U.S. Senator From Ohio

                       NBER WORKING PAPER SERIES

DOES PRIVATE EQUITY INVESTMENT IN HEALTHCARE BENEFIT PATIENTS? EVIDENCE 
                           FROM NURSING HOMES

                               Atul Gupta

                           Sabrina T. Howell

                          Constantine Yannelis

                             Abhinav Gupta

                          Working Paper 28474

                   http://www.nber.org/papers/w28474

                  NATIONAL BUREAU OF ECONOMIC RESEARCH

                       1050 Massachusetts Avenue

                          Cambridge, MA 02138

                             February 2021

We are grateful to Abby Alpert, Pierre Azoulay, Zack Cooper, Liran 
Einav, Matthew Grennan, Arpit Gupta, Jarrad Harford, Steve Kaplan, 
Holger Mueller, Aviv Nevo, Adam Sacarny, Albert Sheen, Arthur Robin 
Williams, and participants at the NBER Aging Summer Institute, American 
Economics Association, UBC Winter Finance Conference, Whistler Junior 
Health Economics Summit, Virtual Corporate Finance Seminar, ESSEC, 
Norwegian School of Economics, Oklahoma Price, PE Research Consortium 
(PERC) Annual Symposium, Tulane, NYU Stern, U Penn Wharton, Yale Health 
Policy, Oregon Lundquist, and Johns Hopkins Carey for their comments 
and suggestions. Jun Wong, Mei-Lynn Hua, and Sarah Schutz provided 
excellent research assistance. We thank Christianna Williams of Abt 
Associates for insights into CMS quality measures, Liz Liberman for 
industry information, and Mohan Ramanujan at NBER for assistance with 
the CMS data. Funding from the Wharton Dean's Research Fund and the 
Mack Institute (Gupta), the Kauffman Foundation (Howell), and the Fama 
Miller Center at the University of Chicago (Yannelis) is greatly 
appreciated. We gratefully acknowledge funding through National 
Institute of Aging pilot grant P01AG005842-31. All remaining errors are 
our own. The views expressed herein are those of the authors and do not 
necessarily reflect the views of the National Bureau of Economic 
Research.

NBER working papers are circulated for discussion and comment purposes. 
They have not been peer-reviewed or been subject to the review by the 
NBER Board of Directors that accompanies official NBER publications.

 2021 by Atul Gupta, Sabrina T. Howell, Constantine Yannelis, and 
Abhinav Gupta. All rights reserved. Short sections of text, not to 
exceed two paragraphs, may be quoted without explicit permission 
provided that full credit, including  notice, is given to the source.

Does Private Equity Investment in Healthcare Benefit Patients? Evidence 
from Nursing Homes Atul Gupta, Sabrina T. Howell, Constantine Yannelis, 
and Abhinav Gupta
NBER Working Paper No. 28474
February 2021
JEL No. G3,G32,G34,G38,I1,I18

                                ABSTRACT

The past two decades have seen a rapid increase in Private Equity (PE) 
investment in healthcare, a sector in which intensive government 
subsidy and market frictions could lead high-powered for-profit 
incentives to be misaligned with the social goal of affordable, quality 
care. This paper studies the effects of PE ownership on patient welfare 
at nursing homes. With administrative patient-level data, we use a 
within-facility differences-in-differences design to address non-random 
targeting of facilities. We use an instrumental variables strategy to 
control for the selection of patients into nursing homes. Our estimates 
show that PE ownership increases the short-term mortality of Medicare 
patients by 10%, implying 20,150 lives lost due to PE ownership over 
our twelve-year sample period. This is accompanied by declines in other 
measures of patient well-being, such as lower mobility, while taxpayer 
spending per patient episode increases by 11%. We observe operational 
changes that help to explain these effects, including declines in 
nursing staff and compliance with standards. Finally, we document a 
systematic shift in operating costs post-acquisition toward non-patient 
care items such as monitoring fees, interest, and lease payments.

Atul Gupta                          Constantine Yannelis
Wharton Health Care Management      Booth School of Business
3641 Locust Walk, CPC 306           University of Chicago
Philadelphia, PA 19104              5807 S. Woodlawn Avenue
[email protected]           Chicago, IL 60637
                                    and NBER
Sabrina T. Howell                   [email protected]
                                    u
NYU Stern School of Business
KMC 9-93                            Abhinav Gupta
44 West 4th Street                  New York University
New York, NY 10012                  [email protected]
and NBER
[email protected]

1 Introduction

The U.S. spends more than other developed countries on healthcare, yet 
has worse health outcomes (Garber and Skinner, 2008). In light of 
evidence from other sectors, private equity (PE) ownership of 
healthcare providers could improve productivity (Kaplan, 1989; Davis et 
al., 2014; Bloom et al., 2015b; Bernstein and Sheen, 2016). PE 
ownership can affect firm performance because it confers distinct 
incentives to quickly and substantially increase firm value.\1\ 
However, PE's success in other sectors may not be relevant to 
healthcare, which suffers from unique market frictions. For example, 
patients cannot accurately assess provider quality, they typically do 
not pay for services directly, and a web of government agencies act as 
both payers and regulators (Cutler, 2011; Skinner, 2011). These 
features weaken the natural ability of a market to align firm 
incentives with consumer welfare and could mean that high-powered 
incentives to maximize profits have detrimental implications for 
consumer welfare (Hansmann, 1980; Hart et al., 1997; Chandra et al., 
2016).
---------------------------------------------------------------------------
    \1\ See Section 2.2 for an explanation of PE and its incentive 
structure.

    Policymakers appear increasingly concerned about this possibility 
given the rapid growth of PE in healthcare. For example, in 2019 U.S. 
Senators asked about ``the role of PE firms in the nursing home care 
industry, and the extent to which these firms' emphasis on profits and 
short-term return is responsible for declines in quality of care,'' 
while a member of the British Parliament argued that PE-owned nursing 
homes in the UK pursue ``profiteering, cost and corner cutting, all the 
while their owners are loading them up on debt with high interest rates 
and expecting the taxpayer to pay when it fails'' (Brown et al., 2019; 
Hodgson, 2020).\2\ Meanwhile, voices from the private sector often 
paint a different picture; for example, a 2019 report from consulting 
firm EY concluded that ``Not only is PE perceived to have a beneficial 
overall impact on health care businesses, it is also considered to 
positively influence the focus on quality and clinical services'' 
(Saenz, 2019).
---------------------------------------------------------------------------
    \2\ Policymaker concern has focused not only on nursing home 
quality (Doggett et al., 2020), but also surprise medical bills (Cooper 
et al., 2020) and predatory acquisitions of physician practices (King, 
2020), among other areas. Also see Flood (2019) and Lewis (2019).

    This debate has come to the fore in part because of rising PE 
activity in U.S. healthcare over the last two decades, with total 
investment increasing from less than $5 billion in 2000 to more than 
$100 billion in 2018 (Appelbaum and Batt, 2020). PE-owned firms provide 
the staffing for more than one-third of emergency rooms, own large 
hospital and nursing home chains, and are rapidly expanding ownership 
of physician practices.\3\ Thus far, evidence to inform the animated 
policy discussion is limited and inconclusive.
---------------------------------------------------------------------------
    \3\ See Bruch et al. (2020); Brown et al. (2020); Casalino (2020).

    We focus on nursing homes in the U.S., which represent a large 
sector with spending at $166 billion in 2017 projected to grow to $240 
billion by 2025 (Martin et al., 2018). Nursing homes offer an 
attractive setting in which to examine the impact of PE in healthcare. 
First, they have historically had a high rate of for-profit ownership 
(about 70%), allowing us to study the effects of PE ownership relative 
to for-profit ownership more generally. Second, PE firms have acquired 
both large chains and independent facilities, enabling us to make 
progress in isolating the effects of PE ownership from the related 
phenomenon of corporatization in medical care (Eliason et al., 2020). 
We use patient- and facility-level administrative data from the Centers 
for Medicare and Medicaid Services (CMS), which we match to PE deal 
data. The data include 18,485 unique nursing homes between 2000 and 
2017. Of these, 1,674 were acquired by PE firms in 128 unique deals. We 
---------------------------------------------------------------------------
observe about 7.4 million unique Medicare patients.

    We overcome two empirical challenges to estimating causal effects 
of PE ownership. The first is non-random selection of acquisition 
targets. To address this we include facility fixed effects, which also 
eliminate cross-sectional differences in the types of locations where 
PE firms tend to buy nursing homes. The second challenge is unobserved 
changes in patient composition following PE ownership, perhaps 
reflecting new advertising, hospital ties, or patient reactions to 
quality. We control for the patient-facility match with a differential 
distance instrumental variables (IV) strategy (McClellan et al., 1994; 
Grabowski et al., 2013; Card et al., 2019), exploiting patient 
preference for a nursing facility close to their home (the median 
distance is 4.6 miles). To our knowledge, no national study on PE or on 
ownership in healthcare has simultaneously addressed both challenges.

    A key measure of patient welfare is short-term survival. We find 
that going to a PE-owned nursing home increases the probability of 
death during the stay and the following 90 days by 1.7 percentage 
points, about 10% of the mean. This estimate implies about 20,150 
Medicare lives lost due to PE ownership of nursing homes during our 
sample period. We use the observed age and gender distribution of 
Medicare decedents to estimate the corresponding implied loss in life-
years--160,000. Using a conventional value of a life- year from the 
literature, this estimate implies a mortality cost of about $21 billion 
in 2016 dollars. To put this in perspective, this is about twice the 
total payments made by Medicare to PE facilities during our sample 
period, about $ 9 billion.

    The mortality effect is concentrated among older patients, 
especially those with relatively low disease burdens. Exploring 
treatment effect heterogeneity more formally using Marginal Treatment 
Effect (MTE) analysis, we find evidence of reverse selection on 
treatment gains, i.e., patients with the lowest unobserved resistance 
to going to a PE-owned facility experience the highest increase in 
mortality (nearly 4 pp). We estimate an unconditional Average Treatment 
Effect (ATE) of about 1.3 pp. Hence, the conclusion that patients are 
worse off at PE-owned facilities can be generalized beyond compliers to 
the average Medicare patient. However, we also estimate negative MTE 
values for patients with the highest unobserved resistance, implying 
that a small fraction of patients are better off receiving care at such 
facilities.

    The effect on mortality is robust to a battery of specification 
checks, and does not appear in a placebo analysis testing for pre-
buyout effects. It also remains intact when we restrict our attention 
to PE acquisitions of the largest chains, in which chain size remained 
constant over the sample period, implying that the effect reflects the 
nature of ownership rather than consolidation or corporatization more 
broadly. To ensure the effect is not spurious, we study other measures 
of patient well-being using the same IV approach. We find that going to 
a PE-owned nursing home increases the probability of taking 
antipsychotic medications--discouraged in the elderly due to their 
association with greater mortality--by 50%. Similarly, patient mobility 
declines and pain intensity increases post-acquisition. Finally, the 
amount billed per 90-day episode increases by 11%. Taken together, 
these results suggest that PE ownership decreases nursing home 
productivity, as measured by our proxies for quality output per dollar 
spent.

    To explore mechanisms for the effect on mortality, we assess 
operational changes using facility-level data. Here we are limited to 
using a differences-in-differences research design, which has been 
standard in the literature on PE effects. We find negative effects on 
facility Five Star ratings, which are constructed by CMS to provide 
summary information on quality of care. We next consider nurse 
availability, which is the most important determinant of quality of 
care (Zhang and Grabowski, 2004; Lin, 2014). We find that PE ownership 
leads to a 3% decline in hours per patient-day supplied by the 
frontline nursing assistants who provide the vast majority of 
caregiving hours and perform crucial well-being services such as 
mobility assistance, personal interaction, and cleaning to minimize 
infection risk and ensure sanitary conditions. Overall staffing 
declines by 1.4%.

    The loss of front-line staff is most problematic for older but 
relatively less sick patients, who drive the mortality result. There 
may be less scope to reduce the costs of care for the sicker patients, 
as they have explicit medical needs. Elevated antipsychotic use could 
also be partly explained as a substitution response to lower nurse 
availability (Cawley et al., 2006). We can explain about a third of the 
mortality effect using previously published mortality effects of 
antipsychotics and lower nurse availability and assuming these factors 
are additive (Schneider et al., 2005; Tong, 2011). However, this may be 
an understatement if these factors are more harmful when they interact.

    Finally, we assess facility finances to shed light on how the 
financial strategies particular to the PE industry affect operations. A 
puzzle is why nursing homes are attractive targets given their low and 
regulated profit margins, often cited at just 1-2%. Using CMS cost 
reports, we find that there is no effect of buyouts on net income, 
raising the question of how PE firms create value. There are three 
types of expenditures that are particularly associated with PE profits 
and tax strategies: ``monitoring fees'' charged to portfolio companies, 
lease payments after real estate is sold to generate cash flows, and 
interest payments reflecting the importance of leverage in the PE 
business model (Metrick and Yasuda, 2010; Phalippou et al., 2018). We 
find that all three types of expenditures increase after buyouts, with 
interest payments rising by over 300%. These results, along with the 
decline in nurse availability, suggest a systematic shift in operating 
costs away from patient care.

    This paper contributes to three strands of the literature. First, 
we provide new evidence on the effects of PE ownership on target firm 
operations (Boucly et al., 2011), product quality (Lerner et al., 2011; 
Fracassi et al., 2020), and value (Gupta and Van Nieuwerburgh, 2019; 
Bernstein et al., 2019; Biesinger et al., 2020). We overcome most 
limitations of previous studies on PE in healthcare, such as limited 
geographies, a short sample period, a lack of patient-level data, or a 
small number of deals (Stevenson and Grabowski, 2008; Harrington et 
al., 2012; Pradhan et al., 2013, 2014; Cadigan et al., 2015; Huang and 
Bowblis, 2019; Gondi and Song, 2019; Casalino, 2020; Gandhi et al., 
2020).

    In contrast with much of the existing literature, and likely 
reflecting the considerable market frictions in healthcare, our results 
suggest that PE owners may breach implicit contracts with stakeholders 
to maximize profits (Shleifer and Summers, 1988). Eaton et al. (2019) 
come to the same conclusion in their study of PE ownership of colleges. 
It is noteworthy that nursing homes operate under much more intense 
regulatory scrutiny of their daily operations than do colleges. Hence, 
our results raise concerns about the effectiveness of the elaborate 
state and federal oversight infrastructure in place to ensure nursing 
home quality.

    Second, this paper adds to the literature on how provider ownership 
interacts with price incentives and regulation in healthcare Duggan 
(2000); Grabowski and Hirth (2003); Grabowski et al. (2013); Clemens 
and Gottlieb (2014); Adelino et al. (2015); Hill et al. (2019); Curto 
et al. (2019).\4\ Some work points to non-pecuniary objectives of 
nonprofits as one reason nonprofit providers can outperform for-
profits. Our results appear consistent with this theme, potentially 
raising questions about whether antitrust regulators should 
prospectively review PE deals in healthcare. While the large deals in 
our sample did not soften competition, they may have hurt consumers.\5\
---------------------------------------------------------------------------
    \4\ There is also a related literature on competition in healthcare 
markets: Bloom et al. (2015a), Curto et al. (2021); Grabowski and Hirth 
(2003); Dafny et al. (2012); Cooper et al. (2018); Pelech (2018); Ho 
and Lee (2019).
    \5\ The largest deals in our sample involved purchases of nursing 
home chains owning hundreds of facilities already and which remained 
stable in size. Both the U.S. House and Senate are considering 
expanding the scope of the prevailing anti-trust laws. As example, see 
https://www.cnbc.com/2021/02/04/klobuchar-unveils-sweeping-antitrust-
bill-laying-out-her-vision-as-new-subcommittee-chair-.html.

    Third, this paper contributes to the emerging literature on the 
industrial organization of the nursing home sector, which has received 
less attention than hospitals in economics (Lin, 2015; Hackmann and 
Pohl, 2018; Hackmann, 2019). Previous work has focused on the role of 
competition and payment rates in determining quality. Our results imply 
that owner incentives are of first-order importance, which may be 
helpful for policymakers as they consider regulatory actions to improve 
transparency and accountability. For example, in light of prior work 
showing how PE increases performance when incentives between investors 
and consumers are well-aligned, government reimbursements targeting 
outcomes could potentially improve patient welfare. These issues have 
become more urgent as the COVID-19 pandemic has exposed flaws in the 
regulation and financing of long-term care facilities, which have 
accounted for nearly 40% of U.S. deaths from the virus.\6\
---------------------------------------------------------------------------
    \6\ Source: The New York Times Coronavirus Tracker, as of October 
2020.

    The paper proceeds as follows. Section 2 provides institutional 
background. Section 3 describes the data. The strategy for patient-
level analysis is explained in Section 4, and the results are in 
Section 5. The facility-level estimation is in Section 6. Section 7 
concludes.

2 Institutional Background

2.1 The Economics of Nursing Homes

Nursing homes provide both short-term rehabilitative stays--usually 
following a hospital procedure--as well as long-term custodial stays 
for patients unable to live independently. There are two unique 
features of the long-term care market in the U.S. relative to other 
healthcare subsectors. First, government payers (Medicaid and Medicare) 
account for 75% of revenue, while private insurance plays a much larger 
role in other subsectors (Johnson, 2016).\7\ Second, about 70% of 
nursing homes are for-profit, which is a much larger share than other 
subsectors. For example, fewer than one-third of hospitals are for-
profit. Policymakers have long been concerned about low-quality care at 
nursing homes in the U.S. and for-profit ownership has often been 
proposed as a causal factor (Institute of Medicine, 1986; Grabowski et 
al., 2013).\8\
---------------------------------------------------------------------------
    \7\ Medicaid is a means-tested insurance program targeted at low 
income and disabled non-
elderly individuals. It is the primary payer for custodial care and 
accounts for about 60% of nursing home patient-days in our data. 
Medicare is an entitlement health insurance program for individuals 
older than age 65, and it covers limited short-term rehab care 
following hospital inpatient care, accounting for 15% of patient-days.
    \8\ This concern is frequently reflected in the popular media, 
including as a reason for high death rates from COVID-19 in nursing 
homes. For example, a New York Times article in December, 2020 asserted 
that: ``Long-term care continues to be understaffed, poorly regulated 
and vulnerable to predation by for-profit conglomerates and private-
equity firms. The nursing aides who provide the bulk of bedside 
assistance still earn poverty wages, and lockdown policies have forced 
patients into dangerous solitude'' (Kim, 2020).

    As with any business, the economics of nursing homes are shaped by 
the nature of demand, the cost structure, and the regulatory 
environment. On the demand side, nursing homes serve elderly patients 
but are paid by third-party, largely government payers. Over 95% of 
facilities treat both Medicare and Medicaid patients (Harrington et 
al., 2018). Both programs pay a prospectively set amount per day of 
care for each covered patient (``per diem''), which does not 
incorporate quality of care, reputation, or other determinants that 
would be considered by a well-functioning market. These rates are non-
negotiable, and facilities simply choose whether they will accept 
beneficiaries of these programs. Medicare fee-for-service pays much 
more, at roughly $515 per patient day relative to $209 per patient day 
from Medicaid.\9\ Overall profit margins are in the low single digits 
(MedPAC, 2017), a topic we return to at the end of the paper. Payments 
are adjusted for patient complexity, so there is an incentive to 
overstate their severity--a practice known as ``up-coding.'' This makes 
it difficult to use risk as an outcome.
---------------------------------------------------------------------------
    \9\ https://skillednursingnews.com/2019/03/medicare-advantage-eats-
into-margin-gains-for-skilled-nursing-facilities/. Medicaid still pays 
more than the marginal cost of treatment per day. Hackmann (2019) 
calculates that the marginal cost of treatment per-day is about $160 on 
average.

    Nursing homes provide institutional care and so have high fixed 
costs, making the occupancy rate an important driver of profitability. 
Nursing staff represent the largest component of operating cost, at 
about 50% (Dummit, 2002). Broadly speaking, there are three types of 
nurses. Low-skill Certified Nurse Assistants (CNAs) account for about 
60% of total staff hours and provide most of the direct patient care. 
Licensed Practical Nurses (LPNs) have more training and experience than 
CNAs but cannot manage patients independently. Registered Nurses (RNs) 
have the highest skill and experience levels, and can independently 
determine care plans for patients. LPNs and RNs each account for about 
20% of nurse hours. Nurse availability is crucial to the quality of 
care and there is a consensus that low ratios of nursing staff to 
residents are associated with higher patient mortality and other 
adverse clinical outcomes (Tong, 2011; Lin, 2014). Staffing ratios are 
therefore standard metrics to examine nursing home quality (Hackmann, 
---------------------------------------------------------------------------
2019).

    Economists have long emphasized the importance of information 
asymmetry between patients and healthcare providers (McGuire, 2000). It 
is difficult for patients to assess nursing home quality and compare it 
to available alternatives, and as discussed above, price is not a 
helpful quality signal in this setting. Reputation is therefore likely 
to have an unusually large influence on demand for nursing homes 
(Arrow, 1963). Profit maximizing facilities should optimally invest in 
building and sustaining their reputation. This creates a dynamic 
incentive problem where they could generate higher profits in the 
short-term by cutting patient care costs (nursing staff, for example), 
but they may optimally sacrifice these short-term profits in order to 
maintain their reputation and safeguard patient demand for the long-
term. It remains unclear which factor inputs affect nursing home 
reputation, but evidence from prior studies suggests that patient 
demand does not respond to poor quality scores on government mandated 
report cards (Grabowski and Town, 2011; Werner et al., 2012).

2.2 The Economics of Private Equity Control

PE firms conduct leveraged buyouts (LBOs), in which a target firm is 
acquired primarily with debt financing--which is placed on the target 
firm's balance sheet--and a small portion of equity.\10\ PE is 
associated with particularly high-powered incentives to maximize 
profits because fund managers are compensated through a call option-
like share of the profits, employ large amounts of leverage 
collateralized with target firm assets, aim to liquidate investments 
within a short time frame, and do not have existing relationships with 
target firm stakeholders (Kaplan and Stromberg, 2009). Specifically, 
the compensation of the General Partners (GPs) who manage PE funds 
stems primarily from increasing portfolio company value between the 
time of the buyout and an exit, when the company is sold to another 
firm or taken public. GPs typically receive 20% of profits after a 
hurdle rate, which the fund's investors (Limited Partners) are 
guaranteed before GPs receive any profits. GPs also receive transaction 
and monitoring fees, which are not tied to performance. Overall, 
however, PE managers typically do not earn returns if the business 
continues as-is, motivating aggressive value-creation strategies. In 
contrast, a traditional business owner running the firm as a long-term 
going concern with a lower debt burden may prefer lower but more stable 
profits.
---------------------------------------------------------------------------
    \10\ Kaplan and Stromberg (2009) provide a detailed discussion of 
the PE business model and review the academic evidence on their 
effects. In the interest of brevity, we limit our discussion.

    A large literature in finance beginning with Kaplan (1989) and 
Kaplan and Schoar (2005) has shown that in part due to the call option-
like nature of GP compensation, PE buyouts increase productivity, 
operational efficiency, and generate higher returns. Kaplan and 
Stromberg (2009) argue that PE owners increase firm value through three 
channels, which they call financial, governance, and operations 
engineering. The first channel includes the alleviation of credit 
constraints (Boucly et al., 2011), which may lead to increases in 
investment and improved operations, and exploiting the favorable tax 
code treatment of debt financing (Spaenjers and Steiner, 2020), which 
---------------------------------------------------------------------------
may increase financial stress and the chances of default.

    Governance engineering includes a number of changes to the 
compensation, benefits, and composition of the management team at the 
target firm to align their incentives with those of the PE owners. For 
example, in addition to frequently changing key managers, PE owners 
also increase the equity stake of the management team and introduce 
performance-based compensation (Gompers et al., 2016). Bloom et al. 
(2015b) show that PE-owned firms are better managed than similar firms 
that are not PE-owned.

    Operations engineering refers to the more recent practice of PE 
firms applying their industry expertise to add value to their 
investments. PE owners identify both strategic and operational 
opportunities, such as re-branding, organization restructuring, 
investing in new technology, expanding to new markets, and cost-cutting 
(Gadiesh and MacArthur, 2008; Acharya et al., 2013; Bernstein and 
Sheen, 2016). Davis et al. (2014) show that PE buyouts are linked to 
greater labor churn, the expansion of efficient operations and the 
closure of inefficient operations.

    Considering these changes in the context of nursing homes, the 
effects on patients are theoretically ambiguous. On the one hand, 
better management, stronger incentives, and access to credit may lead 
to improvements in care quality. On the other hand, three forces could 
adversely affect quality. The first is that cost cutting measures and a 
focus on capturing subsidies could come at the expense of quality 
improvement efforts. The second is that the nursing home incurs a large 
debt obligation as part of the buyout, and the resulting interest 
payments can reduce the cash available for care. A related additional 
cost is leasing property that formerly was owned by the nursing home. 
PE owners often sell real estate assets shortly after the buyout, which 
generates cash that can be returned to investors. Such cash flows early 
in the deal's lifecycle boost ultimate discounted returns. For example, 
in one of the largest PE deals in our sample, the Carlyle Group bought 
HCR Manorcare for about $6.3 billion in 2007, of which roughly one 
quarter was equity and three-quarters were debt. Four years later, 
Carlyle sold the real estate assets for $6.1 billion, offering 
investors a substantial return on equity (Keating and Whoriskey, 2018). 
Afterward, HCR Manorcare rented its facilities; the monthly lease 
payments are essentially another debt obligation, and a Washington Post 
investigation found that quality of care deteriorated following the 
real estate sale (Keating and Whoriskey, 2018).

    Finally, the third force is the relatively short-term time horizon 
of PE investments,which could push managers to focus on maximizing 
short-term profits even if they come at the expense of long term 
reputation and performance. In the case of HCR Manorcare, the nursing 
home chain was ultimately unable to make its interest and lease 
payments and entered bankruptcy proceedings in the spring of 2018. 
Carlyle sold its stake to the landlord.

3 Data and Descriptive Statistics

In this section we briefly summarize our data sources and provide 
descriptives about the sample, including an analysis of PE targeting. 
In Appendix A, we describe these elements in comprehensive detail.

3.1 Data

We obtained facility-level annual data between 2000 and 2017 from 
publicly available CMS sources. In each year we observe about 15,000 
unique skilled nursing facilities (we use the term ``nursing home'' 
interchangeably), for a total of approximately 280,000 observations. 
These data include variables such as patient volume, nurse 
availability, and various components of the Five Star ratings. The 
ratings first appear in 2009. Fortunately, half of the PE deals in our 
sample occurred after 2009.

    Our second data source consists of patient-level data for Medicare 
beneficiaries from 2004 to 2016. We use the Medicare enrollment and 
claims files (hospital inpatient, outpatient, and nursing homes) for 
the universe of fee-for-service Medicare beneficiaries. We merge these 
files with detailed patient assessments recorded in the Minimum Data 
Set (MDS) to obtain additional clinical insights. These data are 
confidential and were accessed under a data use agreement with CMS. 
They include patient enrollment details, demographics, mortality, and 
information about care in nursing homes and hospitals during this 
period.

    In patient-level analysis, the unit of observation is a nursing 
home stay for a Medicare beneficiary that begins during our sample 
period, which we begin in 2005 in order to have at least one look-back 
year. We consider only the patient's first nursing home stay in our 
entire sample period so that we can unambiguously attribute outcomes to 
one facility and make our patient sample more homogeneous. This 
produces a sample of more than seven million patients over 12 years. We 
are most interested in the effect on mortality, which is an 
unambiguously bad outcome, has little measurement error, and is 
difficult to ``game'' on the part of a facility or a government agency. 
For these and other reasons, short-term mortality (with suitable risk 
adjustment) has become the gold-standard measure of provider quality in 
the health economics and policy literature (McClellan and Staiger, 
1999). We use an indicator for death during the stay or within 90 days 
following discharge, based on death dates recorded in the Medicare 
master beneficiary summary file. There is a high level of short-term 
mortality--one in six patients die within three months of discharge--
indicating the general morbidity of this patient cohort.

    We use two measures of spending: the amount billed to Medicare for 
the patient stay, and the amount for the stay plus the following 90 
days, in case better quality care leads to lower subsequent spending 
(both in 2016 dollars). Medicare covers the entire cost until the 21st 
day of stay, at which point the patient begins paying a coinsurance. 
Consequently, about 90% of total payments in our data are made by 
Medicare and patients bear the remainder. We complement the mortality 
analysis by examining some ancillary measures of patient well-being 
using the clinical assessments. We study four outcomes that CMS uses 
when computing the Five Star quality ratings for nursing homes. The 
first is an indicator for the patient starting antipsychotic medication 
during the stay. Antipsychotic use in the elderly is known to increase 
mortality, and non-pharmaceutical interventions such as music and 
breathing exercises have been shown to be more effective (Taragano et 
al., 1997; Kuehn, 2005; Sink et al., 2005; Schneider et al., 2005; 
Banerjee et al., 2011; Press and Alexander, 2013). The second is an 
indicator for the patient's self-reported mobility score declining 
during the stay. The third is an indicator for developing a pressure 
ulcer. The fourth is an indicator for the patient's self-reported pain 
intensity score increasing during the stay.

    To identify nursing homes acquired in PE deals, we make use of a 
proprietary list of transactions in the ``elder and disabled care'' 
sector compiled by Pitchbook Inc., a leading market intelligence firm 
in this space. The deals span 2004 to 2015, so that we will have 
sufficient time to evaluate outcomes. We match the target names to 
individual nursing facilities using name (facility or corporate owner) 
and address as recorded in the CMS data. This process yields 128 deals, 
which correspond to a change in ownership to PE for 1,674 facilities. 
The vast majority of deals in Pitchbook are not at hazard of matching, 
as they concern assisted living or other elder care companies that are 
not Medicare-accepting skilled nursing facilities. (See Appendix A for 
details.)

    Figure B.1 shows the number of deals in each year; the deals are 
spread over time, and no part of the business cycle dominates. The 
deals are also spread across PE firms. In total, our data contain 136 
unique PE firms that acquired nursing homes. Most deals are syndicated 
and involve multiple PE firms. Table B.1 presents the top 10 deals by 
number of facilities acquired. On average, we observe PE-owned 
facilities for eight years post-acquisition. Hence the results should 
be interpreted as medium to long-term effects of PE ownership. It is 
difficult to ascertain whether we comprehensively capture PE activity 
in this sector. While there is no ``official'' tally of PE-owned 
nursing homes to benchmark against, our sample size compares favorably 
against an estimate of 1,876 nursing homes reportedly acquired by PE 
firms over a similar duration, 1998-2008 (GAO, 2010). The PE investors 
in our sample include very large funds, smaller funds, and specialized 
healthcare PE investment funds. The funds which account for the 
greatest number of deals are Onex, Fillmore Capital Partners, The 
Hillview Group, The Carlyle Group, Cammeby International, Heritage 
Partners, Lydian Capital, Formation Capital, and Oaktree.

3.2 Descriptive Statistics

Overall, PE investment in healthcare has increased dramatically in 
recent decades, as shown using Pitchbook data in Panel A of Figure 1. 
Panel B focuses on the Elder and Disabled Care sub-sector, which 
includes the nursing homes that we study as well as assisted living and 
other types of care. The shaded areas in the graphs correspond to years 
after our sample ends, and indicate that deal activity continued to 
accelerate beyond 2015. The bottom two panels describe the skilled 
nursing facilities in our CMS data that are PE-owned. As of 2015, PE-
owned facilities represented about 9% of all nursing facilities in the 
data, corresponding to an annual flow of about 100,000 patients. Note 
that the large spike in the mid-2000s seen in all the graphs reflects 
an economy-wide PE boom during this period, and is not specific to 
healthcare. Similarly, the flat lining in Panels C and D starting in 
2010 reflects the lull in deal activity due to the Great Recession. 
Given the patterns in Panel B, the share of facilities that are PE-
owned is likely substantially higher today.

    Table 1 Panel A presents summary statistics on key variables used 
in the analysis at the facility-year level, where a facility is a 
single nursing home. Panel B presents summary statistics at the unique 
patient level on the final Medicare patient sample (recall we focus on 
a patient's first stay). PE targets are slightly larger, have fewer 
staff hours per resident, and a lower Overall Five Star rating. At the 
sector level, ratings and staffing have secularly increased over time. 
For staffing, this reflects more stringent standards from regulators 
over time. As the PE deals occurred primarily later in the sample, it 
is therefore remarkable that they have lower measures of quality on 
average. Panel B shows that demographic measures are similar across the 
types of facilities, such as patient age and a high-risk indicator.\11\ 
PE-owned facilities bill about 10% more per stay than non-PE 
facilities.
---------------------------------------------------------------------------
    \11\ We use the Charlson Comorbidity Index, a standard measure of 
patient mortality risk based on co-morbidities. We create a high-risk 
indicator that is equal to one if the previous-year Charlson score is 
greater than two.

    We describe which characteristics are associated with buyouts in 
Table A.1. Facilities in more urban counties and in states with higher 
elderly population shares are more likely to be targeted.\12\ County-
level income, race, and home ownership do not predict buyouts. Chain-
owned facilities are more likely to be acquired than independent 
facilities, likely reflecting the fixed costs of a PE deal. A higher 
share of Medicare patients (the omitted group) is positively associated 
with being targeted. Finally, the Five Star overall rating has a 
negative relationship with buyouts, indicating that PE firms target 
relatively low-performing nursing homes. These factors remain 
statistically significant predictors when included simultaneously in 
the same model, shown in column 5. These results highlight the need to 
estimate the effects of PE ownership within-facility.
---------------------------------------------------------------------------
    \12\ The map in Figure B.2 shows that deals are not excessively 
concentrated in particular areas of the country.
---------------------------------------------------------------------------

4 Empirical Strategy for Patient-Level Analysis

There are two primary concerns related to measuring the causal effects 
of PE ownership on patient-level outcomes. First, PE funds may target 
facilities that are different in ways the econometrician cannot 
observe. To address this concern, we include facility fixed effects, 
eliminating time invariant differences across facilities. Second, 
following a PE buyout, the composition of patients may change, 
confounding the analysis. Differential customer selection following PE 
ownership could reflect both supply-side channels such as changes in 
advertising and hospital referrals, or patient perceptions about PE 
ownership.

    Recent studies have documented that nursing homes can select 
patients based on patient characteristics, only some of which are 
observable to CMS (Hackmann and Pohl, 2018; Gandhi, 2020). We see 
evidence of changes in patient risk following PE ownership in our data. 
Table B.5 Panel A presents point estimates from differences-in-
differences models that exploit variation in the timing of the PE deals 
across facilities. We test for changes in patient risk (assessed at the 
time of admission) following acquisition. We examine effects on a mix 
of acute and chronic conditions to broadly capture changes in patient 
risk. The coefficients indicate that patients are less likely to suffer 
from Dementia and Alzheimers or from acute conditions like Hip 
Fractures at the time of admission. However, they are also more likely 
to have a Urinary Tract Infection (UTI). Figure B.3 presents the 
corresponding event study plots, which generally suggest flat or 
declining trends in patient risk around the time of the acquisition. We 
are concerned that if there is a similar decline in unobserved patient 
risk following PE ownership, it will bias downward mortality and 
spending effects obtained via OLS. Therefore, we develop an instrument 
for the match between patients and nursing homes.

4.1 Distance Instrument

We use a differential distance instrument (McClellan et al., 1994) to 
control for endogenous patient selection into nursing homes. The 
instrument exploits the well-known patient preference for nearby 
healthcare providers (Einav et al., 2016; Card et al., 2019; Currie and 
Slusky, 2020). This is especially true for nursing homes; for example, 
Hackmann (2019) finds that the median distance between a senior's 
residence and her nursing home is under 4.3 miles. This is also evident 
in our data--the median and 90th percentile distances between a patient 
and her nursing home are 4.6 and 18 miles, respectively. About 35% of 
all patients choose the facility located closest to them (see Figure 
B.4).\13\ As a result of these patterns, this instrument has been 
useful in the nursing home setting to control for patient selection 
(Grabowski et al., 2013; Huang and Bowblis, 2019).
---------------------------------------------------------------------------
    \13\ Distance patterns remain remarkably stable over time in our 
sample. Mean distance to facility is unaffectedby PE buyout, as shown 
in Figure B.4D.

    We compute the difference (in miles) between two distances: from a 
patient's home zip code to the closest PE-owned facility zip code; and 
from the patient's residence to the nearest non-PE facility zip code. A 
positive value indicates the patient is closer to a non-PE facility. A 
lower differential distance value implies the nearest PE-owned facility 
is closer to the patient. PE ownership evolves over time as more deals 
take place (and some PE funds exit their investments), creating 
variation across years in differential distance for individuals 
residing in the same zip code. Following convention in the literature, 
we drop patients with outlier differential distance values.\14\
---------------------------------------------------------------------------
    \14\ Specifically, we drop patients with a differential distance 
value beyond 70 miles, which is approximately the 95th percentile 
(i.e., the nearest PE facility is 70 miles further than the nearest 
non-PE facility). The concern here is that these patients are plausibly 
located in a different market which PE facilities do not operate in, 
and hence could differ in unobserved ways correlated with health or 
spending outcomes. To be symmetric, we also drop (the very few) 
patients who have a differential distance value below -70.

    The first stage is estimated using Equation (1), and the second 
stage is estimated using Equation (2). The endogenous regressor of 
interest PEi,j,r,t is an indicator set to one if patient i 
in Hospital Referral Region (HRR) r chooses PE-owned facility j in year 
t. We instrument with linear and squared differential distance, Di 
applicable to patient i based on her zip code, z, and when the nursing 
---------------------------------------------------------------------------
home stay began.

[GRAPHIC] [TIFF OMITTED] T1721.001


.epsOur preferred model controls for facility, aj, and 
patient HRR by year fixed effects, ar,t. The vector 
Xi,z denotes patient risk controls including age, indicators 
for gender, marital status, dual eligible, and 17 disease 
categories.\15\ We conduct multiple robustness checks, which include 
adding time-varying socioeconomic variables at the patient's zipcode-
year level and omitting all controls.\16\ Standard errors are clustered 
by facility to account for unobserved correlation in outcomes across 
patients treated at the same nursing home.
---------------------------------------------------------------------------
    \15\ To construct these indicators, we use diagnoses codes recorded 
in claims billed over the three months prior to the index nursing home 
stay (hospital stays, ED visits, and outpatient visits).
    \16\ The socioeconomic variables, from the American Community 
Survey, are annual median household income, the share of the population 
that are white, that are renters rather than home-owners, and that are 
below the Federal poverty line.

    The instrument is strongly predictive of choice of nursing home 
type. The first stage results are reported in Table 2. Column 2 
presents the estimates from our preferred specification. A five mile 
decrease in differential distance (0.3 s.d.) increases the probability 
of going to a PE-owned nursing home by 2.3 percentage points (pp), a 
quarter of the mean level. The F-statistic exceeds 200, well above 
conventional rule-of-thumb thresholds for weak instruments.

4.2 Instrument Assumptions and Validation Tests

IV estimation differs from randomized controlled trials because the 
randomization of patients to treatment is indirect rather than 
deliberate. As in all such analyses, we must rely on two untestable 
identification assumptions. The first is conditional random assignment, 
which requires that after conditioning on covariates, unobserved 
characteristics correlated with the outcomes of interest are not 
correlated with differential distance. This assumption subsumes the 
exclusion restriction, that the instrument affects outcomes only 
through its effect on the patient's probability of going to a PE 
facility. The second assumption is monotonicity, which assumes that a 
decrease in differential distance makes all patients more likely to 
choose a PE-owned facility. This is true on average, but the assumption 
is at the patient-level which is untestable. Monotonicity is necessary 
to interpret the IV estimate as a well-defined local average treatment 
effect (LATE).

    An important test for randomization examines whether differential 
distance is correlated with covariates, particularly those which may 
affect health outcomes, such as risk. Comparing the estimates reported 
in columns 1 and 2 of Table 2, the coefficients on differential 
distance are nearly unaffected by including patient-level controls, 
consistent with random assignment. Figure 2 Panel A visually presents 
the relationship between patient risk and the instrument and indicates 
little or no correlation.\17\
---------------------------------------------------------------------------
    \17\ We project the high-risk indicator (see Section A.2) on the 
controls we use in our main regression, and collapse the residuals into 
twenty bins. Similarly, we run a regression of differential distance on 
the controls and collapse the residuals into twenty bins. We plot the 
means of each bin, with the risk residuals on the Y-axis and distance 
residuals on the X-axis. The figure also presents a fitted line and the 
slope coefficient.

    Additional evidence for random assignment is that patient 
characteristics are similar for high and low values of differential 
distance. We document this in Table 3, where we summarize 21 patient 
characteristics for above- and below-median differential distance 
values. The top two rows of the table show that, consistent with a 
strong instrument, below-median differential distance average is 2.7 
miles, while the above-median average is 27 miles. The associated 
probability of going to a PE-owned facility declines from 17% to 2%. 
The patient characteristics in the subsequent rows are extremely 
similar across the two groups. For example, 64% of each group are 
women, and about a quarter of the patients in both groups have 
diabetes. While differential distance is highly predictive of going to 
a PE-owned facility, it appears to randomize patients with respect to 
---------------------------------------------------------------------------
observed covariates.

    PE funds may strategically target nursing homes located in places 
with certain desired demographic and risk profiles. We account for 
stable differences in the patient catchment of facilities by including 
facility fixed effects. However, it is possible that PE firms 
strategically target geographic markets with desirable trends, for 
example with increasing household income. To address this concern, we 
show robustness to including time-varying zip code-level socioeconomic 
controls. We document that these controls do not affect the first stage 
in Column 3 of Table 2. The use of HRR-specific year fixed effects 
further mitigates the possibility of differential market trends biasing 
the effects.

    A related concern may be that HRRs are too large and do not 
sufficiently control for unobserved heterogeneity in trends across 
markets. Hence, we also test robustness to using the more granular 
market definition of Health Service Areas (HSA) and counties.\18\ There 
are nearly 800 HSAs and 3,000 counties, respectively, while there are 
only about 300 HRRs. Columns 4 and 5 of Table 2 present results using 
these finer market definitions, respectively, with slightly smaller 
estimates.
---------------------------------------------------------------------------
    \18\ HSAs were developed by the National Center for Health 
Statistics of the Centers for Disease Control in the mid 1990s. They 
are designed to identify a single county or contiguous sets of counties 
where Medicare patients seek hospital care within the area. We use a 
slightly modified version developed by the SEER program of the National 
Cancer Institute, available for download at https://seer.cancer.gov/ 
seerstat/variables/countyattribs/hsa.html.

    We provide evidence consistent with the monotonicity assumption in 
Figure 2 Panel B, which contains a binscatter plot of the first stage, 
showing that the likelihood of going to a PE-owned facility increases 
nearly linearly with differential distance. It is estimated in the same 
way as Panel A described above, except that the outcome is an indicator 
for the facility being PE-owned. The monotonicity assumption also 
implies that the first stage should be negative when estimated on sub-
samples of patients with different characteristics. Table B.2 shows 
that when we estimate the relationship between below-median 
differential distance and PE ownership (a simplified first stage), we 
recover coefficients that are very similar to the full-sample result 
and all are significant at the .01 level for a variety of sample splits 
---------------------------------------------------------------------------
by age, gender, race, and zip code income level.

    Table B.2 also helps characterize compliers relative to the average 
patient at a PE facility. The ratio of the first stage coefficient for 
a subsample with a specific attribute to that obtained for the full 
sample provides the likelihood of compliers having that particular 
attribute relative to the average PE patient.\19\ Compliers appear to 
have a very similar age distribution and the probability of being male, 
married, or white. Intuitively, distance-based compliers are more 
likely to be from a low-income zip code.
---------------------------------------------------------------------------
    \19\ This follows from Bayes rule and the use of a discrete 
instrument in this model of the first stage. The coefficient from a 
subsample with attribute X is P(M|X) = P(X|M)P(M)/P(X) where M denotes 
a marginal PE patient. Dividing by the first stage coefficient for the 
full sample, P(M), gives us P(X|M)/P(X), the relative likelihood.
---------------------------------------------------------------------------

5 Patient-Level Effects

This section presents the main results of the paper. We focus on the 
effects of PE ownership on short-term mortality and spending per 
patient, discussing the LATE, heterogeneity in treatment effects, as 
well as tests for the mechanism and robustness.

5.1 Main Effects on Mortality and Spending

Table 4 presents the results obtained by estimating Equation (2). These 
models include 22 patient-level controls (described in Section 4.1), 
facility fixed effects, and patient HRR- by-year fixed effects. Column 
1 indicates that receiving care at a PE-owned nursing home increases 
the probability of death during the stay and the following 90 days by 
1.7 pp, about 10% of the mean. In the context of the health economics 
literature, this is a very large effect. This estimate remains stable 
in magnitude at about 10% of the mean regardless of the time horizon 
studied (see Table B.3).

    We calculate the implied cost in statistical value of life-years in 
Table B.4 Panel A. We translate the IV coefficients into lives and 
life-years lost based on the number of index stays by patients of PE-
owned nursing homes during our sample period. Accordingly, we compute 
about 20,150 additional deaths due to PE ownership over our twelve-year 
sample period. To estimate life-years lost, we rely on observed 
survival rates for Medicare patients at all nursing homes. This leads 
to an estimate of about 160,000 lost life-years.\20\ Applying a 
standard estimate of statistical value of a life-year of $100,000 
(Cutler and McClellan, 2001), inflated to 2016 dollars, this implies a 
mortality cost of $20.7 billion.
---------------------------------------------------------------------------
    \20\ As life expectancy differs substantially between men and 
women, we estimate the effect separately by gender. We calculate the 
average life expectancy at discharge by gender by observing the actual 
life span for each patient in our data. For patients still alive at the 
end of our sample period, we approximate the year of death based on 
patient gender and age using Social Security actuarial tables. We 
adjust this downward to account for the fact that decedents tend to be 
older on average (by about 2 years). We then applied this mean life 
expectancy to the number of deaths computed above and obtained the 
number of life-years lost. This approach may overstate the true value 
if the incremental deaths at PE facilities are of older patients. This 
approach also understates the true value since we don't account for the 
loss in longevity not resulting in death.

    The next two columns of Table 4 Panel A consider spending per 
patient. In our data, more than 90% of the billed amount is paid by 
taxpayers through Medicare and patients pay the balance. The amount 
billed per nursing home stay increases by 19.5% (column 2; note it is 
necessary to exponentiate coefficients larger than .1 when the outcome 
is logged). As Table 1 shows, on average PE-owned nursing homes bill 
$14,800 per stay, while non-PE nursing homes bill $13,500. This does 
not seem to reflect additional preventive care that is compensated for 
by lower subsequent needs, because the total amount billed for both the 
stay and the 90 days following the stay (the episode) increases by 
---------------------------------------------------------------------------
about 11%.

    The most important robustness test we conduct is a placebo 
analysis, which probes whether spurious trends rather than the 
ownership change might explain the results. We use Medicare patient-
level data from 2002-07, a period with little PE ownership of nursing 
homes and little overlap with our main sample. We randomly set the PE 
dummy to turn on in 2004 or 2005 for facilities that eventually were 
acquired by PE firms later. Further, we discard data for any facility 
starting with the year it actually got acquired. We recompute 
differential distances under these ``placebo'' assignments and estimate 
our main IV models. Table 4 Panel B presents these placebo estimates 
and reassuringly finds small and insignificant effects, implying a lack 
of differential trends prior to acquisition.

    Our IV estimates imply that the reduced form effect on mortality 
and spending should decline as differential distance grows larger 
(i.e., relative to the nearest alternative, a PE facility is farther 
away). Figure 3 visually confirms this pattern. The figure plots 
coefficients from regressing each outcome on indicators for quintile of 
differential distance, with the furthest quintile as the reference 
group using our preferred controls as in the main specification. By 
using quantile dummies, this specification is flexible and does not 
impose linearity with respect to differential distance. We find the 
largest effects among patients in the bottom two quintiles of 
differential distance, i.e., those located nearest to PE-owned 
facilities.

    Results from OLS models are presented in Table B.5 and the 
corresponding event studies are in Figure B.5. They suggest no pre-
trends, consistent with the parallel trends assumption that underlies 
our empirical model (i.e., target facilities and control facilities 
would continue on parallel trends in the absence of the buyout). We 
observe a statistically significant, but much smaller increase in 
mortality in the OLS model (0.3 pp). This is only one-sixth the size of 
the IV estimate, consistent with unobservedly lower risk patients 
matching with PE-owned facilities. In a similar vein, we also find 
small, negative effects on spending (1-2% decrease) and length of stay 
(not presented).

5.2 Heterogeneity in the Mortality Effect

This section explores heterogeneity both on observed attributes and on 
unobserved resistance to treatment, using a Marginal Treatment Effects 
(MTE) framework.

5.2.1 Observed Attributes

To assess heterogeneity in the IV analysis, we split the sample based 
on observed characteristics. We first consider four groups based on 
patient risk and age. We expect that higher age is associated with a 
greater need for attentive but not necessarily high-skill or complex 
care, for example helping patients to use the toilet and minimizing 
infection risk.

    Higher risk--a measure constructed from disease burdens--should be 
associated with more need for high-skill, medicalized RN care. Older, 
high risk patients require the most intensive and high-skill care. 
Therefore, we split the sample into four groups around the median age 
of 80 and around the high-risk indicator (Charlson score above two). 
The results, shown in Table 5 Panel A, document that the effect on 
mortality is driven by patients who are low risk, with the most robust 
result among patients who are low risk but above-median age. This group 
accounts for nearly half of the sample. The high risk, above-median age 
group also has a large, positive coefficient, but it is noisy. In 
contrast, the point estimate for high-risk but below-median age 
patients is negative and marginally significant. This suggests that PE-
owned nursing homes are able to take better care of more complex 
patients, especially when they are on the younger side. But lower risk 
or older patients suffer.

    We find positive effects among both men and women, but the effect 
is larger and much more robust among female patients, who represent 65% 
of the sample and are on average older. The effect is also larger among 
patients from above-median income zip codes.\21\ It is also larger 
among White patients. Finally, the last set of results divide the 
sample into three categories corresponding to the patient's reason for 
hospitalization prior to the nursing home stay; we find the largest 
effect for patients who were hospitalized due to cardiovascular 
disease.
---------------------------------------------------------------------------
    \21\ We do not observe beneficiary income directly, so we assign 
individuals to above-median and below-median income neighborhoods based 
on their zip code.

    There is evidence that for-profit incentives generally and PE 
ownership specifically are associated with lower quality of care in 
more concentrated markets (Gandhi et al., 2020), so we examine in Panel 
B whether the effects vary by market competition, using the Herfindahl-
Hirschman Index (HHI) of the hospital referral region (HRR). We find 
that the coefficient is larger among nursing homes in below-median HHI 
areas, but the coefficient is more precise among nursing homes in 
above-
median HHI areas. As both coefficients are relatively close to our main 
estimate, concentration does not appear to be a driving factor.

5.2.2 MTE Theory and Estimation Approach

The LATE may mask treatment effect heterogeneity across different types 
of patients. For example, some patients may benefit from the type of 
care that is offered by PE-owned facilities, even though we estimated 
negative impacts on average for the complier group. It also ignores the 
possibility of patient selection on treatment gains. The MTE framework 
allows us to examine these dimensions (Heckman and Vytlacil, 2005; 
Heckman et al., 2006). It enables us to compute treatment effect 
parameters of economic interest such as the Average Treatment Effect 
(ATE) and Treatment on the Treated (ATT). Unlike the LATE, these 
parameters are not specific to the complier group and allow us to make 
more general statements regarding the causal effects of PE ownership.

    We denote Y0,i and Y1,i as potential outcomes 
for individual i in the untreated (k = 0) and treated (k = 1) states, 
respectively. Treatment in our setting is receiving care at a PE-owned 
facility, PEi. We model these potential outcomes Yk,i 
as a function of observed control vector Xi and dummies for 
facility, Fj and market-year interactions, Rr,t. 
Uk,i denotes all unobserved factors.\22\
---------------------------------------------------------------------------
    \22\ Following Brinch et al. (2017), we assume that the error term 
Uk,i is normalized to be conditional mean zero, i.e., E[U|X 
= x, F = f, R = r] = 0.

[GRAPHIC] [TIFF OMITTED] T1721.002


.epsWe then propose a latent selection model of how patients choose a 
---------------------------------------------------------------------------
PE-owned facility based on observed and unobserved factors.

[GRAPHIC] [TIFF OMITTED] T1721.003


.epswhere Z = (X, F, R, D, D2) is a vector including all the 
controls listed above in Equation (3) and the differential distance 
instruments excluded from the outcome equation, Di and 
Di2. We interpret Vi as the unobserved 
resistance to going to a PE-owned facility. This selection model 
imposes monotonicity by using a constant parameter d for all 
individuals. Following the MTE literature, we transform the selection 
equation into the quantiles of the distribution of V rather than its 
absolute values:

[GRAPHIC] [TIFF OMITTED] T1721.004


.epswhere F is the cumulative distribution function of Vi. 
We interpret F(Z,i,d) as the propensity score, the 
probability that an individual with observed characteristics Zi 
chooses a PE nursing home, and denote it as P(Z). F(Vi) 
represents the quantiles of unobserved resistance to treatment, and is 
denoted as UD.

    Omitting subscripts for simplicity, the MTE is defined as MTE(X = 
x, UD = u) = E[Y1 - Y0|X = x, UD 
= u]. The MTE is the treatment gain for an individual with 
characteristics X = x, who is in the uth quantile of the 
resistance distribution. Such individuals are indifferent to receiving 
treatment when their propensity score P(Z) equals u.

    We make two untestable assumptions to estimate the MTE. The first, 
as in Section 4.2, is random assignment of the instrument, conditional 
on observables. The second assumption is of functional form. Following 
the convention in the recent MTE literature (Brinch et al., 2017; 
Cornelissen et al., 2018), we assume that the MTE is additively 
separable into an observed and unobserved component. This allows the 
MTE to be identified over the unconditional support of P(Z) across all 
values of X rather than the support of P(Z) conditional on X = x, 
easing the burden of identifying variation needed from the data 
(Carneiro et al., 2011).

[GRAPHIC] [TIFF OMITTED] T1721.005


    .epsAnother implication of this assumption is that treatment effect 
heterogeneity due to X affects the MTE curve in u only through the 
intercept. The slope of the MTE curve in u does not depend on X, 
facilitating estimation. The potential outcomes model described above 
produces the following outcome equation as a function of observables 
and P(Z) (Carneiro et al., 2011).

[GRAPHIC] [TIFF OMITTED] T1721.006


.epswhere K(p) is a nonlinear function of the propensity score. The 
derivative of this outcome equation with respect to p estimates the 
marginal treatment effect at X = x and UD = p (Heckman et 
al., 2006).

    We first estimate the selection model in Equation (4) using a 
linear probability model and obtain p = Z,d. Figure 4 Panel A presents 
the variation in the estimated propensity score. We collapse the data 
to percentiles of differential distance, D and plot a non-parametric 
fit of P(Z) values against the corresponding percentile means of D. 
This shows a similar pattern first observed in Figure 2--the 
probability of going to a PE-owned facility declines nearly 
monotonically as differential distance increases. However, this figure 
masks the full support of the distribution of P(Z), which extends over 
the entire unit interval. Figure 4 Panel B highlights the overlap in 
distribution of the propensity scores for treated and untreated 
patients by plotting histograms for the two groups against P(Z) on the 
X-axis. We use log scales on the Y-axes since there are large numbers 
of observations at the two extremes of propensity score. The figure 
confirms that the treated and untreated groups overlap in distributions 
over nearly the entire unit interval, enabling the estimation of the 
unconditional ATE without the need for extrapolation (Basu et al., 
2007). We then estimate the outcome Equation (8) below, assuming K(p) 
is a polynomial in p of degree S.

[GRAPHIC] [TIFF OMITTED] T1721.007


    .epsThe MTE curve is the derivative of Equation (8) with respect to 
p. In our baseline model we set S = 2, but test robustness to using 
higher order polynomials. Standard errors are obtained by block 
bootstrap, clustering by facility.

5.2.3 MTE Results

We estimate Equation (8) and confirm the presence of selection on 
unobserved resistance by testing the joint significance of the 
coefficients rs on the higher order terms of the polynomial 
in p (Heckman et al., 2006). The coefficient on p2 is highly 
statistically significant (p value < 0.01), confirming patient 
selection into PE facilities on unobserved resistance.

    Figure 4 Panel C presents the MTE curve along with 90% confidence 
intervals. Our primary approach uses a second degree polynomial, so the 
MTE curve is linear in unobserved resistance (u). Since it is downward 
sloping, there is reverse selection on treatment gains; that is, 
individuals with the least resistance to going to a PE facility 
experience the worst mortality effects of nearly 4 pp. In contrast, 
individuals with the highest resistance experience marginally negative 
(i.e., beneficial) effects. The MTE values are not statistically 
significant for individuals with above median resistance to treatment. 
The figure also plots the ATE, which is 1.3 pp (s.e. 1.4 pp). To test 
sensitivity to the linearity assumption, we also estimate the MTE curve 
with 3rd, 4th, and 5th degree polynomials. Figure B.6 Panel B shows 
that the curve remains downward sloping regardless of the polynomial.

    We aggregate the marginal treatment effects using the appropriate 
weights to obtain various treatment effect parameters such as the 
unconditional ATE and ATT (Cornelissen et al., 2016). Given the 
downward sloping nature of the MTE curve, we expect the average effect 
on the treated to be higher than that for the untreated. Figure 4 Panel 
D presents the weights to apply to the MTE values to compute the ATT 
and ATUT. Accordingly, we estimate an ATT of 3.1 pp (s.e. 0.9 pp) and 
an ATUT of 1.0 pp (0.9 pp). Only the ATT is statistically significant 
among the three treatment effect parameters.

    There are two key takeaways from this analysis. First, the ATE 
implies that a randomly chosen Medicare patient from our sample would 
experience an increase of 1.3 pp in the probability of short-term 
mortality if she chose a PE-owned nursing home. While about a third 
lower than the LATE estimate, it nevertheless implies a large number of 
deaths in a counterfactual where all Medicare short-stay patients 
receive care at a PE-owned facility. Second, the MTE curve implies 
reverse selection on gains and that some patients--those with greater 
resistance to treatment--experience improvements in mortality if they 
choose a PE-owned facility, though the negative MTE values are not 
statistically significant. This pattern is consistent with the 
heterogeneity in treatment effects on observed attributes. For example, 
we find a large and statistically significant increase in mortality for 
individuals residing in zip codes with greater than median income (see 
Table 5 row 3). Individuals in richer neighborhoods are also about 20% 
more likely to choose PE-owned facilities--their mean propensity score 
is 12 pp versus 10 pp for patients from neighborhoods with income below 
the median. In contrast, we find a smaller and statistically 
insignificant effect for individuals in lower income neighborhoods.

5.3 Patient Well-Being and Mechanism Tests

If the effect on short-term mortality is related to lower patient 
welfare, we expect to see consistent evidence using other well-being 
measures. Therefore, we also use the IV model to assess effects on the 
four clinical measures of well-being that CMS uses as outcomes for 
short-stays when computing Five Star ratings (surprisingly, mortality 
is not one of them). The first is whether a patient starts taking 
antipsychotic drugs. As discussed in Section 3, antipsychotics are 
discouraged in the elderly due to their association with mortality and 
the greater efficacy of behavioral interventions. We find that going to 
a PE-owned nursing home increases the chances of starting 
antipsychotics by 3 pp, or 50% of the mean (Table 6 column 1). Using an 
estimate from the literature on how antipsychotic medications affect 
mortality, this coefficient implies that about 15% of the total effect 
on mortality is potentially attributable to starting 
antipsychotics.\23\
---------------------------------------------------------------------------
    \23\ Several clinical studies have examined the harmful effects of 
antipsychotic prescribing for the elderly. The most relevant study for 
our purposes is by Schneider et al. (2005), who perform a meta-analysis 
of 15 randomized controlled trials (11 from nursing homes) that studied 
the effects of antipsychotics on mortality for elderly patients. They 
report a 50% increase in mortality. The trials evaluated mortality at 
durations averaging about 3 months, coincidentally matching our 
mortality measure. Applying a 50% increase in mortality to our setting 
implies an 8 pp increase in 90-day mortality on a mean of 17 pp. We 
apply this elevated mortality effect to the 3 percent additional 
patients at PE facilities who receive antipsychotics. This implies an 
increase in mortality of 8  0.03 = 0.24 pp for PE patients on average.

    We also find a positive effect on experiencing worsening mobility, 
which increases by 4.3 pp, or about 8% of the mean (Table 6 column 2). 
We do not find a significant effect on the third measure--developing 
ulcers--though the coefficient is positive (column 3). Fourth, there is 
a positive effect on increasing pain intensity of 2.7 pp, which is 10% 
of the mean. Figure B.5 presents the corresponding event studies and 
indicate no differential pre-trends.\24\ Overall, the evidence of 
harmful effects on other measures of patient well-being are 
comfortingly consistent with the estimated effects on mortality.
---------------------------------------------------------------------------
    \24\ Results using OLS models are in Table B.5B. They are typically 
smaller in magnitude (except ulcers), consistent with selection leading 
to downward bias in OLS.

    Thus far we have assumed that ownership type explains any effects 
of PE buyouts. Alternatively, PE ownership could bring economies of 
scale or corporatization, which are the explanation that Eliason et al. 
(2020) propose for negative effects of dialysis center mergers. To test 
this hypothesis, we conduct three tests in Table 7. The first adds to 
our main model a control for being a chain versus an independent 
facility. If our effects are explained by the ``rolling-up'' of 
independent facilities into more efficient chains, the estimates should 
attenuate. Instead, they are essentially unchanged. The second test 
excludes the top two deals the buyouts of the very large Genesis 
Healthcare and Golden Living chains (both have more than 300+ 
facilities). The coefficient is larger, implying that our result is not 
driven by the very largest chains. The most important test is in row 4, 
where we use only the top five deals to define PE ownership. In these 
deals, the target chains already owned more than 100 facilities and 
stayed nearly the same size over the sample period. Therefore, in this 
model chain size is held constant and we evaluate the effect of a 
change in ownership. Again, the effect is larger than in the full 
sample. In sum, it does not seem that chain corporate structures or 
---------------------------------------------------------------------------
synergies in large firms explain our results.

    Another concern is whether the results are spuriously capturing the 
quality difference between for-profit and nonprofit nursing 
facilities.About 20% of the patients receive treatment at a nonprofit 
facility. By definition these facilities are part of the control group. 
We test the sensitivity of our main estimate to excluding these 
facilities from the sample altogether. Row 5 presents the corresponding 
results and shows that the estimate reducesabout 20% in magnitude but 
remains statistically significant.

    The remaining rows of Table 7 report robustness tests that vary the 
controls and market definitions. If the instrument does not randomly 
assign patient risk, we expect patient controls to substantially affect 
the results. Instead, the results are robust to alternative controls, 
consistent with random assignment. The first test in this group (row 6) 
includes zip-year socioeconomic controls. The coefficients decline only 
slightly. The next two rows use the more granular HSAs and counties, 
respectively, to define patient markets instead of HRRs. The final row 
omits all patient controls, estimating larger effects, but well within 
two standard errors of the main estimate. Overall, the results are 
quite stable.

6 Operational Changes

This section uses facility-level data to explore operational changes 
that could help explain the adverse patient welfare effects described 
in the previous section.

6.1 Empirical Strategy

For outcomes available only at the nursing home level, we cannot 
instrument for patient selection and the best possible research design 
therefore is differences-in-
differences. We use variants of the following specification:

[GRAPHIC] [TIFF OMITTED] T1721.008


.epsPEj,t takes a value of one if facility j is PE-owned in 
year t. The coefficient of interest is b, which captures the 
relationship between PE ownership and the outcome Yj,t. We 
include facility (aj) and year fixed effects 
(at). We retain all facilities in our preferred 
specification, but the results are robust to limiting the sample to 
for-profit facilities. The vector Pj,t includes three 
controls for facility-level patient mix and Mj,t includes 
five county-level controls for time-varying market attributes.\25\ As 
there may be concern that control variables could be affected by PE 
ownership, we also present results without any controls.
---------------------------------------------------------------------------
    \25\ Patient mix controls: Case Mix Index (CMI) is a composite 
measure of patient risk based on medical history of diagnosis or 
treatment for a large number of conditions. Second, Acuity index is a 
measure of patient risk computed using the patient's assessed 
Activities of Daily Living (ADL) scores. In both cases, a greater value 
indicates a riskier patient cohort for the nursing home. We winsorize 
both the CMI and Acuity Index at the 1% and 99% level in each year. The 
third control is the share of the facility's patients who are Black. 
County-level controls: Herfindahl Hirschman Index (HHI) based on shares 
of beds, number of for-profits, number of chain-owned, number of 
hospital-based, and number of overall facilities. These are calculated 
using a leave-one-out procedure from the facility-level data.

    The identifying assumption is that PE targets and control 
facilities would continue on parallel trends in the absence of the 
acquisition. We assess whether there are differential pre-trends using 
event study figures, which plot the coefficients bs from 
---------------------------------------------------------------------------
estimating Equation (10) below.

[GRAPHIC] [TIFF OMITTED] T1721.009


.epsDeal Yearj,s is an indicator that is one in year s 
relative to the buyout year for facility j, and zero otherwise. The 
remaining terms are as defined above for Equation (9).

6.2 Results

We consider three types of operational channels. The first two 
explicitly concern facility quality, while the last pertains to 
financial strategies particular to the PE industry. All the results are 
presented in Table 8. For each outcome, the top row of coefficients are 
from specifications with only facility and year fixed effects, while 
the bottom row adds the full set of patient and market controls. Event 
studies are in Figures 5 and 6.

6.2.1 Compliance With Standards and Staff Availability

First, we consider compliance with care protocols in Panel A of Table 
8. Our outcome of interest is the facility-level Five Star rating, 
which varies from one (worst) to five (best). After PE buyouts, the 
Deficiency rating declines by 0.08 points (column 1), which is about 3% 
of the mean and 7% of the standard deviation (the most relevant measure 
given how this variable is constructed). This rating reflects whether 
the facility is satisfying care protocols such as storing and labeling 
drugs properly, disinfecting surfaces, as well as other aspects of care 
such as ensuring resident rights and avoiding patient abuse. The 
Overall rating similarly declines (column 2). Figure 5 presents event 
studies for each outcome. There are no pre-trends, consistent with the 
identifying assumption, and the negative effects appear immediately 
after the change in ownership and persist for at least five years.\26\
---------------------------------------------------------------------------
    \26\ The Overall rating has three components: the Deficiency 
rating, a Quality rating based on metrics computed using claims data 
and clinical assessments, and a Staffing rating, which is based on 
staffing measures evaluated in Panel B. Since we assess quality and 
staffing changes more granularly, we do not present the effects on 
these components, but we find negative, significant effects of equal or 
larger magnitudes there as well.

    In Panel B, we assess effects on nursing staff hours per patient-
day, a well-
established measure of nursing home quality that accounts for changes 
in patient volume. Column 1 shows a modest decline of 0.05 hours in 
aggregate staff hours (1.4% of the mean). This aggregate effect masks 
larger changes for different types of nurses that offset each other. 
There is a decrease in ``front-line'' caregivers (CNAs and LPNs), shown 
in columns 2 and 3, respectively. Together there is a decline of around 
0.09 hours for these two groups (3% of the mean). In contrast, there is 
an increase in use of Registered Nurses (RNs) by about 0.04 hours (8%). 
The event studies in Figure 5 again reveal no pre-trends and indicate 
more immediate declines after the deal in front-line staffing, while 
the increase in RN staffing appears starting in the third year after 
the buyout.\27\ The increase in RN staff hours does not compensate for 
the decline in lower skilled nurse hours because RNs account for a 
small fraction of all staff hours. Medicare cost reports indicate that 
CNAs and LPNs receive an hourly wage that is about 40% and 70% 
respectively of the wage paid to RNs, which is around $35 per hour. 
Unfortunately, we cannot observe whether facilities are taking cost 
reduction steps such as using more part-time labor and reducing 
individual shifts.
---------------------------------------------------------------------------
    \27\ We report the results of robustness tests in Table B.6, which 
include controls for chains, excluding the top two deals, and including 
only for-profit nursing homes.

    The existing literature helps to connect the effects on nurse 
availability with the estimated effect on mortality. Tong (2011) 
exploits an increase in minimum nurse staffing regulation in California 
and finds a decline in on-site patient mortality due to greater 
availability of front-line nurses. Applying her estimates in our 
setting, the estimated decline in front-line nurse staffing predicts an 
increase in mortality of 0.25 pp.\28\ The findings on increased use of 
antipsychotics and lower nurse availability may be related. Grabowski 
et al. (2011) note that antipsychotics are believed to substitute for 
nurse care and show that when nursing homes increase wages, 
inappropriate use of antipsychotics decreases. Therefore, it is 
intuitive that lower staffing--in particular low-skill staffing--would 
be associated with increases in adverse conditions related to lack of 
attention, such as more use of antipsychotics and lower mobility. The 
two channels additively predict an increase in mortality of 0.5 pp in 
our setting (about 30% of our mortality effect). However, this may be 
an underestimate if they produce larger effects when they interact.
---------------------------------------------------------------------------
    \28\ Tong (2011) reports a 15% decline in mortality due to an 
increase in nurse availability of one hour per resident-day. Since we 
estimate a decline of 0.09 hours, this predicts an increase of 0.09  
15 = 1.4% of the mean, or 0.24 pp. More recently, Ruffini (2020) 
exploits variation in minimum wage requirements to isolate the effects 
of nurse staffing changes on quality and also finds mortality effects.

    The increase in RN availability is consistent with the negative 
effects on mortality being driven by older rather than more complex 
patients. RN staff are most relevant for the more medicalized aspects 
of care, while front line nurses support daily living activities such 
as preventing infections and turning patients in bed. One possibility 
is that managers may have looked for ways to cut overall labor costs 
while changing the mix of nursing staff capability to maintain quality 
and patient experience, as RNs are crucial to nursing home quality 
(Zhang and Grabowski, 2004; Lin, 2014). An alternative explanation is 
the regulatory focus on RNs. For example, CMS uses the availability of 
RNs to determine eligibility for Medicare reimbursement.\29\ Given the 
tight regulatory scrutiny of RN availability, it is difficult to reduce 
staffing levels in this category.
---------------------------------------------------------------------------
    \29\ Specifically, such facilities are defined by having ``an RN 
for 8 consecutive hours a day, 7 days a week (more than 40 hours a 
week), and that there be an RN designated as Director of Nursing on a 
full time basis.'' See https://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/Downloads/som107c07pdf.pdf.

    To explore whether the declines in staff availability and quality 
are related, we compare changes in staff availability and Five Star 
ratings within target facilities around the PE buyout event. This 
analysis recovers correlations and does not imply causality, so we 
present the raw data in bin-scatter plots. Figure B.7 shows the change 
in Five Star rating over the three years around PE acquisition on the 
Y-axis against the change in aggregate staff hours per patient day 
during the same period on the X-axis. The plots show that facilities 
which experienced larger declines in staff availability also 
experienced greater declines in ratings. The patterns are consistent 
across rating types and suggest that cuts to nursing staff may be an 
important channel to explain the quality declines.

6.2.2 Finances and Operations

Our final analysis uses CMS cost reports to analyze key sources of 
expenditure related to the PE business model. We begin by noting that 
nursing homes are widely known to have relatively low and regulated 
profit margins, often cited at just 1-2%.\30\ Our data on nursing home 
cost reports submitted to CMS indicate that nursing homes report 
negative operating margins on average, and PE-owned nursing homes are 
not on average more profitable. In unreported analysis, we see no 
effect of buyouts on net income or overall revenue or costs. This 
raises the question of how PE firms create value from nursing home 
investments.
---------------------------------------------------------------------------
    \30\ http://www.medpac.gov/docs/default-source/data-book/
jun17_databookentirereport_sec.
pdf.
---------------------------------------------------------------------------
    There are three types of firm expenditures that the academic 
literature and popular press particularly associates with profits for 
PE owners. The first is what are often termed ``monitoring fees'' 
charged to portfolio companies. In the CMS cost reports, these are 
listed as ``management fees''--charges to the nursing home for being 
owned and managed by a PE firm.\31\ Metrick and Yasuda (2010) note that 
these are thought to be between 1-5% of EBITDA. Our data suggest that 
they increase over time after buyouts, as shown in Figure 6 Panel A, 
where the fees are flat before the buyout, and then rise dramatically 
afterwards. Table 8 Panel C column 1 indicates that on average, 
management fees increase by 7.7% after acquisition (we exponentiate 
coefficients in this panel as the outcomes are in logs).
---------------------------------------------------------------------------
    \31\ In their summary of buyout fund economics, Metrick and Yasuda 
(2010) write that ``we think of monitoring fees as just another way for 
BO funds to earn a revenue stream.'' These fees should not be confused 
with the usual 2% of fund value that General Partners earn each year 
for managing Limited Partners' capital, before profits from 
investments.

    The second type of expenditure is lease payments. The value of 
underlying real estate is frequently cited as a reason that nursing 
homes and other typically low-margin assets can be profitable 
investments, because the investor can sell the real estate to a related 
company or to a third party (Dixon, 2007; Keating and Whoriskey, 2018; 
Brown, 2019). Cash from the real estate sale can be disbursed as 
profits to the PE fund. A cash inflow early in the life of the 
investment is particularly beneficial to the fund's Internal Rate of 
Return, a key performance metric. The nursing home assumes the 
obligation of future rent payments. As an example, a New York Times 
---------------------------------------------------------------------------
report on the nursing home industry notes that:

        [PE] investors created new companies to hold the real estate 
        assets because the buildings were more valuable than the 
        businesses themselves, especially with fewer nursing homes 
        being built. Sometimes, investors would buy a nursing home from 
        an operator only to lease back the building and charge the 
        operator hefty management and consulting fees (Goldstein et 
        al., 2020).\32\
---------------------------------------------------------------------------
    \32\ Two examples further illuminate these types of transaction. 
First, the HCR Manorcare deal discussed in Section 2.2, where the 
chain's real estate assets were spun off and sold shortly after the 
acquisition by the Carlyle Group. Second, at a Congressional hearing 
the executive director of the Long-Term Care Community Coalition said 
``more and more with entities buying up nursing homes, they have no 
experience in the business, they sell out the underlying property'' 
(Brown, 2019).

Consistent with this strategy, column 2 shows that facility building 
lease payments increase dramatically by about 75% after PE 
acquisitions. Figure 6 Panel B confirms the lack of pre-trends and the 
---------------------------------------------------------------------------
increase post-buyout.

    The third type of expenditure is interest on debt. While not a 
direct source of PE profits, debt is tightly related to the overall PE 
model for creating value. Metrick and Yasuda (2010) note that the ratio 
of debt to equity in a buyout deal is typically around 5:1. The 
interest payments become a cost to the portfolio company. In Figure 6 
Panel C, we see that like the previous two outcomes, interest payments 
are flat before the buyout and then rise dramatically afterwards. 
Column 3 indicates that the increase is about 325%.

    Finally, we find that cash on hand declines after the buyout by 
38%. Unlike the other outcomes, the event study in Figure 6 Panel D 
indicates that cash on hand initially increases after the buyout as 
profits increase and cash is injected, perhaps to invest in efficiency 
improvements. However, as the strategies for returning profit to the 
investors are implemented, such as selling the real estate and thus 
requiring the operator to take on lease payments, the cash on hand 
turns negative. This could make the nursing home less well-equipped to 
manage sudden shocks such as, for example, needing to buy personal 
protective equipment following an infectious disease breakout.

    Taking the results on nurse availability together with the 
estimated effects on interest, lease, and management fees payments, we 
infer that PE ownership shifts operating costs away from staffing 
towards costs that are profit drivers for the PE fund. To our 
knowledge, this paper offers the first instance in the literature on PE 
in which these three profit drivers have been documented 
systematically.

    The final outcome we explore is patient capacity and volume. Table 
B.7 column 1 finds no measurable change in the number of beds, which 
may partly reflect state regulations restricting expansions. Admissions 
increase by 3.5%, or 6.5 patients per year for the average facility 
(column 2). However, we interpret this effect with caution since the 
corresponding event study suggests a pre-trend (Figure B.8B). The 
apparent disconnect between demand and quality of care may reflect 
information frictions in observing nursing home quality, as discussed 
earlier (Arrow, 1963; Grabowski and Town, 2011; Werner et al., 2012).

    Higher admissions raise the question of whether PE ownership 
increases overall access to nursing home care, providing care for 
individuals who would not otherwise have gone to a nursing home. To 
test whether this is the case, we assess the effects of PE entry into a 
nursing home market, using the HRR definition. Table B.7 column 3 shows 
that there is no effect of initial PE entry on admissions at the market 
level, corroborated by flat patterns in the event study (Figure B.8C). 
Hence, the data are more consistent with the facility-level admissions 
increase reflecting business stealing.

7 Conclusion

This paper studies PE buyouts in healthcare, an important sector where 
PE activity has increased dramatically, generating policy debate. 
Nursing homes are a useful setting because they have particularly high 
levels of for-profit ownership and subsidy and have experienced 
extensive PE investments. In an instrumental variables design 
incorporating facility fixed effects, we address both targeting and 
patient selection challenges to identification. We find that going to a 
PE-owned facility increases 90-day mortality by about 10% for short-
stay Medicare patients, while taxpayer spending over the 90 days 
increases by 11%. Furthermore, we document declines in nurse 
availability per patient and in measures of compliance with Medicare's 
standards of care. We also find a corresponding increase in operating 
costs that tend to drive profits for PE funds.

    There are many channels for future work. Although our results imply 
PE ownership reduces productivity of nursing homes, it may have more 
positive effects in other sectors of healthcare with better functioning 
markets. Beyond healthcare, there has been significant PE investment in 
sectors such as education, defense and infrastructure, which like 
healthcare rely on high levels of government subsidy but are 
characterized by opaque product quality. Further work is needed to 
determine how government programs can be redesigned to align the 
interests of PE-owned firms with those of taxpayers and consumers.

References

Acharya, Viral V., Oliver F. Gottschalg, Moritz Hahn, and Conor Kehoe, 
    ``Corporate governance and value creation: Evidence from private 
    equity,'' The Review of Financial Studies, 2013, 26 (2), 368-402.

Adelino, Manuel, Katharina Lewellen, and Anant Sundaram, ``Investment 
    decisions of nonprofit firms: Evidence from hospitals,'' The 
    Journal of Finance, 2015, 70 (4), 1583-1628.

Appelbaum, Eileen and Rosemary Batt, ``Private equity buyouts in 
    healthcare: Who wins, who loses?'', Institute for New Economic 
    Thinking Working Paper Series, 2020, (118).

Arrow, Kenneth J., ``Uncertainty and the welfare economics of medical 
    care,'' The American Economic Review, 1963, 53 (1/2), 941-973.

Banerjee, Sube, Jennifer Hellier, Michael Dewey, Renee Romeo, Clive 
    Ballard, Robert Baldwin, Peter Bentham, Chris Fox, Clive Holmes, 
    Cornelius Katona et al., ``Sertraline or mirtazapine for depression 
    in dementia (HTA-SADD): a randomised, multicentre, double-blind, 
    placebo-controlled trial,'' The Lancet, 2011, 378 (9789), 403-411.

Basu, Anirban, James J. Heckman, Salvador Navarro-Lozano, and Sergio 
    Urzua, ``Use of instrumental variables in the presence of 
    heterogeneity and self-selection: an application to treatments of 
    breast cancer patients,'' Health Economics, 2007, 16 (11), 1133-
    1157.

Bernstein, Shai and Albert Sheen, ``The operational consequences of 
    private equity buyouts: Evidence from the restaurant industry,'' 
    Review of Financial Studies, 2016, 29 (9), 2387-2418.

Bernstein, Shai, Josh Lerner, and Filippo Mezzanotti, ``Private equity 
    and financial fragility during the crisis,'' Review of Financial 
    Studies, 2019, 32 (4), 1309-1374.

Biesinger, Markus, Cagatay Bircan, and Alexander Ljungqvist, ``Value 
    creation in private equity,'' EBRD Working Paper, 2020.

Bloom, Nicholas, Carol Propper, Stephan Seiler, and John Van Reenen, 
    ``The Impact of Competition on Management Quality: Evidence from 
    Public Hospitals,'' Review of Economic Studies, 2015, (82), 457-
    489.

Bloom, Nicholas, Raffaella Sadun, and John Van Reenen, ``Do private 
    equity owned firms have better management practices?'', The 
    American Economic Review, 2015, 105 (5), 442-446.

Boucly, Quentin, David Sraer, and David Thesmar, ``Growth LBOs,'' 
    Journal of Financial Economics, 2011, 102 (2), 432-453.

Brinch, Christian N., Magne Mogstad, and Matthew Wiswall, ``Beyond LATE 
    with a discrete instrument,'' Journal of Political Economy, 2017, 
    125 (4), 985-1039.

Brown, Benjamin, Eloise O'Donnell, and Lawrence P. Casalino, ``Private 
    equity investment in behavioral health treatment centers,'' JAMA 
    Psychiatry, 2020, 77 (3), 229-230.

Brown, Danielle, ``Lawmakers pepper private equity firms on nursing 
    home investments, quality issues,'' McKnight's Long-Term Care News, 
    2019.

Brown, Sherrod, Mark Pocan, and Elizabeth Warren, ``Letter to The 
    Carlyle Group (KewsongLee and Glenn A. Youngkin),'' November 2019.

Bruch, Joseph D., Suhas Gondi, and Zirui Song, ``Changes in hospital 
    income, use, and quality associated with private equity 
    acquisition,'' JAMA Internal Medicine, 2020.

Cadigan, Rebecca Orfaly, David G. Stevenson, Daryl J. Caudry, and David 
    C. Grabowski, ``Private investment purchase and nursing home 
    financial health,'' Health Services Research, 2015, 50 (1), 180-
    196.

Card, David, Alessandra Fenizia, and David Silver, ``The health impacts 
    of hospital delivery practices,'' Technical Report, National Bureau 
    of Economic Research, 2019.

Carneiro, Pedro, James J. Heckman, and Edward J. Vytlacil, ``Estimating 
    marginal returns to education,'' American Economic Review, 2011, 
    101 (6), 2754-81.

Casalino, Lawrence P., ``Private equity, women's health, and the 
    corporate transformation of American medicine,'' JAMA Internal 
    Medicine, 2020.

Cawley, John, David C. Grabowski, and Richard A. Hirth, ``Factor 
    substitution in nursing homes,'' Journal of Health Economics, 2006, 
    25 (2), 234-247.

Chandra, Amitabh, Amy Finkelstein, Adam Sacarny, and Chad Syverson, 
    ``Health care exceptionalism? Performance and allocation in the 
    U.S. health care sector,'' American Economic Review, 2016, 106 (8), 
    2110-44.

Charlson, Mary, Ted P. Szatrowski, Janey Peterson, and Jeffrey Gold, 
    ``Validation of a combined comorbidity index,'' Journal of Clinical 
    Epidemiology, 1994, 47 (11), 1245-1251.

Clemens, Jeffrey and Joshua D. Gottlieb, ``Do physicians' financial 
    incentives affect medical treatment and patient health?'', American 
    Economic Review, 2014, 104 (4), 1320-49.

Cooper, Zack, Fiona Scott Morton, and Nathan Shekita, ``Surprise! out-
    of-network billing for emergency care in the United States,'' 
    Journal of Political Economy, 2020, 128 (9), 3626-3677.

Cooper, Zack, Stuart V. Craig, Martin Gaynor, and John Van Reenen, 
    ``The price ain't right? Hospital prices and health spending on the 
    privately insured,'' The Quarterly Journal of Economics, 2018, 134 
    (1), 51-107.

Cornelissen, Thomas, Christian Dustmann, Anna Raute, and Uta Schonberg, 
    ``From LATE to MTE: Alternative methods for the evaluation of 
    policy interventions,'' Labour Economics, 2016, 41, 47-60.

Cornelissen, Thomas, Christian Dustmann, Anna Raute, and Uta Schonberg, 
    ``Who benefits from universal child care? Estimating marginal 
    returns to early child care attendance,'' Journal of Political 
    Economy, 2018, 126 (6), 2356-2409.

Currie, Janet and David Slusky, ``Does the Marginal Hospitalization 
    Save Lives? The Case of Respiratory Admissions for the Elderly,'' 
    Technical Report, National Bureau of Economic Research, 2020.

Curto, Vilsa, Liran Einav, Amy Finkelstein, Jonathan Levin, and Jay 
    Bhattacharya, ``Health care spending and utilization in public and 
    private Medicare,'' American Economic Journal: Applied Economics, 
    2019, 11 (2), 302-32.

Curto, Vilsa, Liran Einav, Jonathan Levin, and Jay Bhattacharya, ``Can 
    health insurance competition work? evidence from medicare 
    advantage,'' Journal of Political Economy, 2021, 129 (2), 570-606.

Cutler, David M., ``Where are the health care entrepreneurs? The 
    failure of organizational innovation in health care,'' Innovation 
    Policy and the Economy, 2011, 11 (1), 1-28.

Cutler, David M. and Mark McClellan, ``Is technological change in 
    medicine worth it?'', Health Affairs, 2001, 20 (5), 11-29.

Dafny, Leemore, Mark Duggan, and Subramaniam Ramanarayanan, ``Paying a 
    premium on your premium? Consolidation in the U.S. health insurance 
    industry,'' American Economic Review, 2012, 102 (2), 1161-85.

Davis, Steven J., John Haltiwanger, Kyle Handley, Ron Jarmin, Josh 
    Lerner, and Javier Miranda, ``Private equity, jobs, and 
    productivity,'' The American Economic Review, 2014, 104 (12), 3956-
    3990.

Dixon, Kim, ``U.S. Senators probe nursing homes run by private 
    equity,'' Reuters, 2007.

Doggett, Lloyd, Rosa DeLauro, Katie Porter, and Mary Scanlon, ``Letter 
    to Leonard Green and Partners (Jonathan Sokoloff),'' June 2020.

Duggan, Mark G., ``Hospital ownership and public medical spending,'' 
    The Quarterly Journal of Economics, 2000, 115 (4), 1343-1373.

Dummit, Laura A., Nursing homes: Quality of care more related to 
    staffing than spending, U.S. General Accounting Office, 2002.

Eaton, Charlie, Sabrina Howell, and Constantine Yannelis, ``When 
    investor incentives and consumer interests diverge: Private equity 
    in higher education,'' The Review of Financial Studies, 2019.

Einav, Liran, Amy Finkelstein, and Heidi Williams, ``Paying on the 
    margin for medical care: Evidence from breast cancer treatments,'' 
    American Economic Journal: Economic Policy, 2016, 8 (1), 52-79.

Eliason, Paul J., Benjamin Heebsh, Ryan C. McDevitt, and James W. 
    Roberts, ``How acquisitions affect firm behavior and performance: 
    Evidence from the dialysis industry,'' The Quarterly Journal of 
    Economics, 2020, 135 (1), 221-267.

Flood, Chris, ``U.S. Congress examines private equity role in surging 
    healthcare costs,'' The Financial Times, 2019.

Fracassi, Cesare, Alessandro Previtero, and Albert W. Sheen, 
    ``Barbarians at the store? Private equity, products, and 
    consumers,'' Technical Report, National Bureau of Economic Research 
    WP 27435, 2020.

Gadiesh, Orit and Hugh MacArthur, Lessons from private equity any 
    company can use, Harvard Business Press, 2008.

Gandhi, Ashvin, ``Picking your patients: Selective admissions in the 
    nursing home industry,'' Available at SSRN, 2020.

Gandhi, Ashvin, YoungJun Song, and Prabhava Upadrashta, ``Private 
    Equity, Consumers, and Competition: Evidence from the Nursing Home 
    Industry,'' 2020.

GAO, ``Complexity of private investment purchases demonstrates need for 
    CMS to improve the usability and completeness of ownership data,'' 
    Technical Report, September 2010.

Garber, Alan M. and Jonathan Skinner, ``Is American health care 
    uniquely inefficient?'', Journal of Economic Perspectives, 2008, 22 
    (4), 27-50.

Goldstein, Matthew, Jessica Silver-Greenberg, and Robert Gebeloff, 
    ``https://www.nytimes.com/2020/05/07/business/coronavirus-nursing-
    homes.html,'' The New York Times, 2020.

Gompers, Paul, Steven N. Kaplan, and Vladimir Mukharlyamov, ``What do 
    private equity firms say they do?'', Journal of Financial 
    Economics, 2016, 121 (3), 449-476.

Gondi, Suhas and Zirui Song, ``Potential implications of private equity 
    investments in health care delivery,'' Journal of the American 
    Medical Association, 2019, 321 (11), 1047-1048.

Grabowski, David C. and Richard A. Hirth, ``Competitive spillovers 
    across non-profit and for-profit nursing homes,'' Journal of Health 
    Economics, 2003, 22 (1), 1-22.

Grabowski, David C. and Robert J. Town, ``Does information matter? 
    Competition, quality, and the impact of nursing home report 
    cards,'' Health Services Research 46, 2011, 46 (6.1), 1698-1719.

Grabowski, David C., John R. Bowblis, Judith A. Lucas, and Stephen 
    Crystal, ``Labor prices and the treatment of nursing home residents 
    with dementia,'' International Journal of the Economics of 
    Business, 2011, 18 (2), 273-292.

Grabowski, David C., Zhanlian Feng, Richard Hirth, Momotazur Rahman, 
    and Vincent Mor, ``Effect of nursing home ownership on the quality 
    of post-acute care: An instrumental variables approach,'' Journal 
    of Health Economics, 2013, 32 (1), 12-21.

Gupta, Arpit and Stijn Van Nieuwerburgh, ``Valuing private equity strip 
    by strip,'' National Bureau of Economic Research Working Paper, 
    2019.

Hackmann, Martin B., ``Incentivizing better quality of care: The role 
    of Medicaid and competition in the nursing home industry,'' 
    American Economic Review, 2019, 109 (5), 1684-1716.

Hackmann, Martin B. and R. Vincent Pohl, ``Patient vs. provider 
    incentives in long term care,'' Technical Report, National Bureau 
    of Economic Research 2018.

Hansmann, Henry B., ``The role of nonprofit enterprise,'' The Yale Law 
    Journal, 1980, 89 (5), 835-901.

Harrington, Charlene, Brian Olney, Helen Carrillo, and Taewoon Kang, 
    ``Nurse staffing and deficiencies in the largest for-profit nursing 
    home chains and chains owned by private equity companies,'' Health 
    Services Research, 2012, 47 (1pt1), 106-128.

Harrington, Charlene, Helen Carrillo, Rachel Garfield et al., ``Nursing 
    facilities, staffing, residents and facility deficiencies, 2009 
    Through 2016,'' Menlo Park: The Henry J. Kaiser Family Foundation, 
    2018.

Hart, Oliver, Andrei Shleifer, and Robert W. Vishny, ``The proper scope 
    of government: theory and an application to prisons,'' The 
    Quarterly Journal of Economics, 1997, 112 (4), 1127-1161.

Heckman, James J. and Edward Vytlacil, ``Structural equations, 
    treatment effects, and econometric policy evaluation 1,'' 
    Econometrica, 2005, 73 (3), 669-738.

Heckman, James J., Sergio Urzua, and Edward Vytlacil, ``Understanding 
    instrumental variables in models with essential heterogeneity,'' 
    The Review of Economics and Statistics, 2006, 88 (3), 389-432.

Hill, Elaine L., David J.G. Slusky, and Donna K. Ginther, 
    ``Reproductive health care in Catholic-owned hospitals,'' Journal 
    of Health Economics, 2019, 65, 48-62.

Ho, Kate and Robin S. Lee, ``Equilibrium provider networks: Bargaining 
    and exclusion in health care markets,'' American Economic Review, 
    2019, 109 (2), 473-522.

Hodgson, Leah, ``Pandemic deepens woes of UK's private equity-backed 
    nursing homes,'' Pitchbook, 2020, September 21.

Huang, Sean Shenghsiu and John R. Bowblis, ``Private equity ownership 
    and nursing home quality: an instrumental variables approach,'' 
    International Journal of Health Economics and Management, 2019, 19 
    (3-4), 273-299.

Institute of Medicine, Improving the quality of care in nursing homes, 
    Vol. 85, National Academy Press, 1986.

Johnson, Richard W., ``Who is covered by private long-term care 
    insurance,'' Urban Institute. tinyurl. com/yxqklvdz. Retrieved 
    December 2016, 28, 2018.

Kaplan, Steven, ``The effects of management buyouts on operating 
    performance and value,'' Journal of Financial Economics, 1989, 24 
    (2), 217-254.

Kaplan, Steven N. and Antoinette Schoar, ``Private equity performance: 
    Returns, persistence, and capital flows,'' The Journal of Finance, 
    2005, 60 (4), 1791-1823.

Kaplan, Steven N. and Per Stromberg, ``Leveraged buyouts and private 
    equity,'' Journal of Economic Perspectives, 2009, 23 (1), 121-46.

Keating, Dan and Peter Whoriskey, ``Overdoses, bedsores, broken bones: 
    What happened when a private-equity firm sought to care for 
    society's most vulnerable,'' The Washington Post, 2018.

Kim, Tammy, ``This is why nursing homes failed so badly,'' New York 
    Times, 2020, December 31.

King, Robert, ``Private equity firms in Congress' crosshairs with 
    legislation calling for transparency,'' Fierce Healthcare, 2020, 
    February 12.

Kuehn, Bridget M., ``FDA warns antipsychotic drugs may be risky for 
    elderly,'' Journal of the American Medical Association, 2005, 293 
    (20), 2462-2462.

Lerner, Josh, Morten Sorensen, and Per Stromberg, ``Private equity and 
    long-run investment: The case of innovation,'' The Journal of 
    Finance, 2011, 66 (2), 445-477.

Lewis, Adam, ``Blackstone, KKR draw ire from Congress over surprise 
    medical bills,'' 2019.

Lin, Haizhen, ``Revisiting the relationship between nurse staffing and 
    quality of care in nursing homes: An instrumental variables 
    approach,'' Journal of Health Economics, 2014, 37, 13-24.

Lin, Haizhen, ``Quality choice and market structure: A dynamic analysis 
    of nursing home oligopolies,'' International Economic Review, 2015, 
    56 (4), 1261-1290.

Martin, Anne B., Micah Hartman, Benjamin Washington, Aaron Catlin, 
    National Health Expenditure Accounts Team et al., ``National health 
    care spending in 2017: Growth slows to post-Great Recession rates; 
    share of GDP stabilizes,'' Health Affairs, 2018, pp. 10-1377.

McClellan, Mark and Douglas Staiger, ``The quality of health care 
    providers,'' Technical Report 7327, National Bureau of Economic 
    Research Working Paper 1999.

McClellan, Mark, Barbara J. McNeil, and Joseph P. Newhouse, ``Does more 
    intensive treatment of acute myocardial infarction in the elderly 
    reduce mortality?: Analysis using instrumental variables,'' Journal 
    of the American Medical Association, 1994, 272 (11), 859-866.

McGuire, Thomas G., ``Physician agency,'' Handbook of health economics, 
    2000, 1, 461- 536.

MedPAC, ``Report to the Congress: Medicare payment policy,'' March 
    2017.

Metrick, Andrew and Ayako Yasuda, ``The economics of private equity 
    funds,'' The Review of Financial Studies, 2010, 23 (6), 2303-2341.

Pelech, Daria, ``Paying more for less? Insurer competition and health 
    plan generosity in the Medicare Advantage program,'' Journal of 
    Health Economics, 2018, 61, 77-92.

Phalippou, Ludovic, Christian Rauch, and Marc Umber, ``Private equity 
    portfolio company fees,'' Journal of Financial Economics, 2018, 129 
    (3), 559-585.

Pradhan, Rohit, Robert Weech-Maldonado, Jeffrey S. Harman, Alex 
    Laberge, and Kathryn Hyer, ``Private equity ownership and nursing 
    home financial performance,'' Health Care Management Review, 2013, 
    38 (3), 224-233.

Pradhan, Rohit, Robert Weech-Maldonado, Jeffrey S. Harman, and Kathryn 
    Hyer, ``Private equity ownership of nursing homes: implications for 
    quality,'' Journal of Health Care Finance, 2014, 42 (2).

Press, Daniel and Michael Alexander, ``Treatment of behavioral symptoms 
    related to dementia,'' UpToDate. Available at: http://
    www.uptodate.com/contents/treatment-of-behavioral-symptoms-related-
    todementia, 2013.

Ruffini, Krista, ``Worker earnings, service quality, and firm 
    profitability: Evidence from nursing homes and minimum wage 
    reforms,'' Unpublished Mimeo, 2020.

Saenz, Andres, ``How private equity can improve the health of 
    healthcare,'' EY Global Private Equity Report, 2019.

Schneider, Lon S., Karen S. Dagerman, and Philip Insel, ``Risk of death 
    with atypical antipsychotic drug treatment for dementia: Meta-
    analysis of randomized placebo-controlled trials,'' Journal of the 
    American Medical Association, 2005, 294 (15), 1934-1943.

Shleifer, Andrei and Lawrence H. Summers, ``Breach of trust in hostile 
    takeovers,'' in Corporate Takeovers: Causes and Consequences, 
    University of Chicago Press, 1988, pp. 33-68.

Sink, Kaycee M., Karen F. Holden, and Kristine Yaffe, ``Pharmacological 
    treatment of neuropsychiatric symptoms of dementia: A review of the 
    evidence,'' Journal of the American Medical Association, 2005, 293 
    (5), 596-608.

Skinner, Jonathan, ``Causes and consequences of regional variations in 
    health care,'' in Handbook of Health Economics, Vol. 2, Elsevier, 
    2011, pp. 45-93.

Spaenjers, Christophe and Eva Steiner, ``Do private equity investors 
    create value? Evidence from the hotel industry,'' Available at 
    SSRN, 2020.

Stevenson, David G. and David C. Grabowski, ``Private equity investment 
    and nursing home care: Is it a big deal?'', Health Affairs, 2008, 
    27 (5), 1399-1408.

Taragano, Fernando E., Constantine G. Lyketsos, Carlos A. Mangone, 
    Ricardo F. Allegri, and Enrique Comesana-Diaz, ``A 
    double-blind, randomized, fixed-dose trial of fluoxetine vs. 
    amitriptyline in the treatment of major depression complicating 
    Alzheimer's disease,'' Psychosomatics, 1997, 38 (3), 246-252.

Tong, Patricia K., ``The effects of California minimum nurse staffing 
    laws on nurse labor and patient mortality in skilled nursing 
    facilities,'' Health Economics, 2011, 20 (7), 802-816.

Werner, Rachel M., Edward C. Norton, R. Tamara Konetzka, and Daniel 
    Polsky, ``Do consumers respond to publicly reported quality 
    information? Evidence from nursing homes,'' Journal of Health 
    Economics, 2012, 31 (1), 50-61.

Zhang, Xinzhi and David C. Grabowski, ``Nursing home staffing and 
    quality under the nursing home reform act,'' The Gerontologist, 
    2004, 44 (1), 13-23.

Figures and Tables

[GRAPHIC] [TIFF OMITTED] T1721.010


    .eps Note: This figure shows PE deals in healthcare over time. 
Panels A and B present the total capital invested (left axis) and 
number of transactions (right axis) by PE firms in healthcare and 
eldercare, by year. Panels C and D focus on the number of active 
nursing homes owned by PE firms in each year. Panel B presents the 
number of PE-owned facilities (left axis) and patients admitted at 
these facilities (right axis). Note that the total number of facilities 
ever bought by PE firms is larger (1,674) than what is plotted here 
since some of these facilities closed or went back to non PE ownership 
over time. Panel D presents these trends as a percentage of total 
number of facilities and patients admitted, respectively.

[GRAPHIC] [TIFF OMITTED] T1721.011


    .eps Note: This figure presents scatter plots of patient 
characteristics against differential distance to the nearest PE 
facility. The independent variable is the difference in distance (in 
miles) of the nearest PE nursing home to the nearest non-PE nursing 
home for the patient. The dependent variable in Panel A is an indicator 
for the patient to have a Charlson Co-morbidity Index (based on 
diagnoses recorded in hospital inpatient and outpatient claims over the 
3 months before admission to nursing home) greater than 2, and in Panel 
B is an indicator for the nursing home being PE-owned. The data was 
collapsed into 20 equal sized bins and we plot the means of residuals 
in each bin that were obtained from models including facility and 
patient HRR x Year fixed effects, and patient demographics: age, race, 
gender, marital status, and an indicator if patient is dual eligible. 
The figures also present quadratic fitted lines for these plots. Each 
plot also presents the slope coefficient (per 10 miles of differential 
distance) with the corresponding standard error. Standard errors are 
clustered by facility.

[GRAPHIC] [TIFF OMITTED] T1721.012


    .eps Note: This figure presents results from reduced form 
regressions for patient-level outcomes on the instrument, differential 
distance. Each blue point in the figure represents a coefficient bs, 
obtained by estimating the equation Yi = am,t + 
aj + Ss=25b 1(Qdd = s)i + 
g1 Xi + +ei, where 1(Qdd = s)i 
is an indicator for the qth quintile of differential distance. The 
highest quintile group, i.e., individuals relatively furthest away from 
a PE facility, is the reference group. Log total payment in Panel B 
refers to the total payment for the index nursing home stay. Standard 
errors are clustered by facility.

[GRAPHIC] [TIFF OMITTED] T1721.013


    .eps Note: This figure presents results pertaining to Marginal 
Treatment Effects (MTE) analysis using the Medicare patient-level data. 
Panel A presents the ``first stage'' fit of predicted probability of 
treatment or propensity score, w.r.t the instrument. Panel B presents 
the overlap in distributions of PE and non-PE groups by propensity 
score. This plot uses a log scale due to the large number of non-PE 
patients with low propensity. Appendix figure B.6A presents the 
corresponding plot using a linear scale. Panel C presents the MTE curve 
with 90% confidence intervals obtained using block bootstrap and the 
Average Treatment Effect (ATE) estimate. Panel D presents the weights 
for the Average Treatment on the Treated (ATT) and Average Treatment on 
the Untreated (ATUT) and the corresponding estimates. Section 5.2.2 
presents details of the MTE estimation.

[GRAPHIC] [TIFF OMITTED] T1721.014


    .eps Note: This figure presents event studies on quality of care 
measures (Five Star ratings) and Staffing around the time a nursing 
home experiences a PE buyout. Each point in the figures represents the 
coefficient bs obtained by estimating Equation (10) as 
discussed in Section 6. Year = -2 is the omitted point. In Panels A and 
B, we present effects on the Five-star ratings awarded by CMS - 
deficiencies identified by independent contractors in audits and 
overall rating, respectively. A negative effect on ratings implies a 
decline in quality. Panels C to F present results on nurse staffing 
per-patient for all staff, nurse assistants, licensed nurses, and 
registered nurses respectively. All models include facility and year 
fixed effects, patient mix and market controls, as described in Section 
6.1. All dependent variables are winsorized at 1 and 99% level. 
Standard errors are clustered by facility.

[GRAPHIC] [TIFF OMITTED] T1721.015


    .eps Note: This figure presents event studies on facility finances 
around the time a nursing home experiences a PE buyout. Each point in 
the figures represents the coefficient bs obtained by 
estimating Equation (10) as discussed in Section 6. Year = -2 is the 
omitted point. Panels A to D present results on the log of management 
fee cost, building lease cost, interest cost, and cash on hand, 
respectively. All models include facility and year fixed effects, 
patient mix and market controls, as described in Section 6.1. All 
dependent variables are winsorized at 1% and 99% levels. Standard 
errors are clustered by facility.


                                         Table 1: Descriptive Statistics
----------------------------------------------------------------------------------------------------------------
                                           All                          Not PE-owned              PE-owned
                        ----------------------------------------------------------------------------------------
                             Mean           SD          Count         Mean        Count        Mean      Count
----------------------------------------------------------------------------------------------------------------
A. Facility Level
 Attributes
Overall Five-Star               3.17          1.30      138,204         3.20      127,441       2.83     10,763
 Rating
Deficiency Five-Star            2.84          1.25      138,204         2.86      127,441       2.62     10,763
 Rating
Staff Hours per Pat.            3.59          1.49      284,108         3.60      271,118       3.38     12,990
 Day
Nurse Assistant Hours           2.28          0.79      284,108         2.29      271,118       2.06     12,990
 per Pat. Day
Licensed Nurse Hours            0.82          0.46      284,108         0.82      271,118       0.82     12,990
 per Pat. Day
Registered Nurse Hours          0.46          0.57      284,108         0.46      271,118       0.49     12,990
 per Pat. Day
Number of Beds                104.48         56.60      284,108       104.11      271,118     112.34     12,990
Admissions                    184.16        166.97      284,108       180.40      271,118     262.47     12,990
Ratio Black                     0.10          0.17      284,108         0.10      271,118       0.12     12,990
Ratio Medicaid                  0.60          0.24      284,104         0.60      271,114       0.60     12,990
Ratio Medicare                  0.15          0.17      284,104         0.15      271,114       0.18     12,990
Ratio Private                   0.25          0.19      284,104         0.25      271,114       0.22     12,990
Management Fees (2016$)        7,076       120,673      231,795        6,001      219,231     25,833     12,564
Building Lease (2016$)         5,860        80,223      231,826        4,825      219,262     23,919     12,564
Interest Expense              12,911       163,562      231,855        5,588      219,291    140,733     12,564
 (2016$)
Cash on Hand (2016$)       1,110,000    10,600,000      231,811    1,150,000      219,257    516,772     12,554
----------------------------------------------------------------------------------------------------------------
B. Medicare Patient
 Attributes
Age                            81.41          8.10    7,365,953        81.46    6,668,539      80.92    697,414
Female                          0.64          0.48    7,365,953         0.64    6,668,539       0.62    697,414
Black                           0.08          0.27    7,365,953         0.08    6,668,539       0.09    697,414
White                           0.88          0.32    7,365,953         0.88    6,668,539       0.88    697,414
Married                         0.34          0.47    7,365,953         0.34    6,668,539       0.35    697,414
Charlson Score                  0.27          0.44    7,365,953         0.27    6,668,539       0.29    697,414
 (Previous) > 2
Cardio-Vascular Disease         0.18          0.39    7,365,953         0.18    6,668,539       0.18    697,414
Injury                          0.19          0.39    7,365,953         0.19    6,668,539       0.19    697,414
Other                           0.63          0.48    7,365,953         0.63    6,668,539       0.63    697,414
Dual Eligible                   0.18          0.38    7,365,953         0.18    6,668,539       0.17    697,414
Differential Distance          14.87         16.70    7,365,953        16.21    6,668,539       2.11    697,414
 (Miles)
Mortality (Stay + 90            0.17          0.38    7,365,953         0.17    6,668,539       0.18    697,414
 Days)
Starts Anti-Pyschotics          0.06          0.23    7,365,953         0.06    6,668,539       0.06    697,414
Mobility Reduces                0.54          0.50    7,365,953         0.53    6,668,539       0.62    697,414
Develops Ulcers                 0.09          0.28    7,365,953         0.09    6,668,539       0.09    697,414
Pain Intensity                  0.27          0.45    7,365,953         0.27    6,668,539       0.30    697,414
 Increases
Amount Billed per             13,600        12,200    7,365,953       13,500    6,668,539     14,800    697,414
 Patient Stay (2016$)
Amount Billed per             21,100        20,100    7,365,953       20,900    6,668,539     22,600    697,414
 Patient Stay + 90 Days
 (2016$)
----------------------------------------------------------------------------------------------------------------
Note: This table presents descriptive statistics for key variables used in the analysis. Panel A presents
  descriptives on facility-level data for all nursing homes over the years 2000-17 while Panel B presents
  patient-level data for Medicare patients with index stays over the years 2005-16. A unit of observation is a
  facility-year in Panel A and a unique patient in Panel B (since we retain only the first stay per patient).
  Columns 1, 2 and 3 present means, standard deviations and number of observations for the full sample. We
  categorize facilities into two groups. Columns 4 and 5 present means and number of observations at facilities
  that never experienced a PE acquisition or before PE acquisition during our sample period. Columns 6 and 7
  present corresponding values for facilities in the post-buyout period. For most variables, about 10% of the
  observations pertain to facilities that experienced a PE acquisition. Sample sizes differ across variables in
  Panel A since they were sourced from multiple sources or in some cases were reported only for more recent
  years. In Panel A, all continuously varying variables were winsorized at the 1% and 99% levels. We compute the
  Charlson Co- morbidity Index using co-morbidities diagnosed in hospital inpatient and outpatient claims (first
  10 dx codes) over the 3 months prior to, but not including, the index stay. Spending values in Panel B are
  winsorized at the 99% level and deflated to be in 2016 dollars. ``Total'' billing includes hospital inpatient,
  outpatient including emergency department, and nursing home stay spending over the 90 days following discharge
  from the index stay and includes the index stay. The following patient-level variables were sourced from the
  Minimum Data Set (MDS): marriage, antipsychotics, mobility, and pressure ulcers. Medicare patients that could
  not be merged into the MDS (94% match rate) were dropped from the sample. Facilities with less than 100
  Medicare patients over the entire period were omitted from the patient-level sample. If any of the MDS
  variables was missing, then we set the respective indicator to zero. We exclude patients facing a differential
  distance of greater than 70 miles, approximately the 95th percentile value, or below -70 miles.



                                  Table 2: Patient-Level Analysis: First Stage
----------------------------------------------------------------------------------------------------------------
                                  (1)  1(PE)      (2)  1(PE)      (3)  1(PE)      (4)  1(PE)       (5)  1(PE)
----------------------------------------------------------------------------------------------------------------
Differential  Distance             -0.0480***      -0.0480***      -0.0479***      -0.0454***        -0.0419***
(In 10 Miles)                         (0.002)         (0.002)         (0.002)         (0.002)           (0.002)
 
(Differential  Distance)\2\         0.0062***       0.0063***       0.0062***       0.0059***         0.0055***
(In 10 Miles)                         (0.000)         (0.000)         (0.000)         (0.000)           (0.000)
 
Market Controls                                                             Y
Patient Controls                                            Y               Y               Y                 Y
Facility FEs                                Y               Y               Y               Y                 Y
Patient FEs Level                  HRR  Year      HRR  Year      HRR  Year      HSA  Year                  County  Year
 
Observations                        7,365,934       7,365,934       7,358,129       7,365,752         7,365,246
Y-Mean                                   0.09            0.09            0.09            0.09              0.09
F-Stat                                    224             224             222             220               203
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership of the nursing home and the
  patient's differential distance. Each cell presents the coefficient b obtained by estimating Equation (1). The
  independent variable is the difference in distance (both linear and quadratic, in 10 miles) to the nearest PE
  nursing home and the nearest non-PE nursing home for the patient. This is calculated based on distances
  between the respective zip code centroids. The outcome variable is an indicator for whether the nursing home
  serving the patient is PE-owned (=1 if PE-owned, 0 otherwise). Column 1 controls for facility and patient
  market (Hospital Referral Region)  Year fixed effects. Column 2 (our preferred specification) adds controls
  for patient risk controls (indicators for 17 pre-existing conditions used to define the Charlson Co- morbidity
  Index inferred from claims over the three months prior to admission, and sex, age, race, marital status, and
  an indicator if patients are dual eligible). Column 3 adds controls for patient zip-year characteristics:
  median household income, the shares of the population that are white, that are renters rather than home-
  owners, that are below the Federal poverty line, and that are enrolled in the medicare advantage program.
  Column 4 uses the same controls as in col. 2 but defines patient market using a narrower market definition:
  Health Service Area (HSA) instead of HRR. Column 5 uses the same controls as in col. 2 but defines patient
  market using a narrower market definition: County instead of HRR. Standard errors are clustered by facility.



               Table 3: Balance of Patient Characteristics
------------------------------------------------------------------------
                                           (1)  DD <        (2)  DD >
           Patient Attribute                 Median           Median
------------------------------------------------------------------------
Differential Distance                             2.70            27.04
PE-owned Nursing Home                             0.17             0.02
Age                                              81.40            81.42
Female                                            0.64             0.64
Black                                             0.09             0.07
Married                                           0.35             0.34
Dual Eligible                                     0.16             0.19
AMI                                               0.08             0.08
Congestive Heart Failure                          0.22             0.24
PVD                                               0.05             0.05
CEVD                                              0.13             0.14
Dementia                                          0.04             0.05
COPD                                              0.21             0.23
Rheumatoid Arthritis                              0.03             0.03
Peptic Ulcer                                      0.02             0.02
Mild Liver Disease                                0.01             0.01
Diabetes                                          0.21             0.22
Diabetes + Complication                           0.04             0.04
Paraplegia                                        0.03             0.03
Renal Disease                                     0.14             0.13
Cancer                                            0.09             0.08
Severe Liver Disease                              0.01             0.01
Metastatic Cancer                                 0.04             0.04
AIDS                                              0.00             0.00
 
Number of Patients                           3,683,135        3,682,818
------------------------------------------------------------------------
Note: This table presents the balance in patient attributes with respect
  to the instrument: differential distance. We divide patients into two
  groups based on whether their differential distance is below or above
  the median value (8.9 miles). Recall that differential distance (DD)
  is the difference between distance to the nearest PE nursing home and
  the nearest non-PE nursing home for the patient. Column 1 presents the
  means of patient characteristics for patients with DD below the median
  value, while Column 2 presents the means for patients with DD greater
  than the median. Characteristics include four demographics and 17 pre-
  existing co-morbidity indicators used to compute the Charlson Co-
  morbidity Index. Paraplegia includes both partial and complete
  paralysis. We generated indicators for the 17 disease groups using the
  ``charlson'' command in Stata, available at http://fmwww.bc.edu/RePEc/
  bocode/c/charlson.html. We considered diagnosis codes on hospital
  inpatient and outpatient claims over the 3 months prior to, but not
  including, the index nursing home stay.



                                   Table 4: Patient-Level Analysis: IV Results
----------------------------------------------------------------------------------------------------------------
                                                                          (2)  Log Amount      (3)  Log Amount
                                                      (1)  Mortality    Billed  Per Patient  Billed  Per Patient
                                                     (Stay + 90 Days)           Stay            Stay + 90 Days
----------------------------------------------------------------------------------------------------------------
                                                                          A: Main Results
                                                  --------------------------------------------------------------
1(PE)                                               0.0168** P(0.007)   0.1777*** P(0.028)   0.1054*** P(0.024)
 
Observations                                                7,365,934            7,365,934            7,365,934
Y-Mean                                                           0.17                 9.07                 9.57
F-Stat                                                            224                  224                  224
                                                  --------------------------------------------------------------
                                                                        B: Placebo Analysis
                                                  --------------------------------------------------------------
1(PE)                                                  0.006 P(0.004)      -0.015 P(0.018)      -0.016 P(0.016)
Observations                                                7,159,535            7,159,535            7,159,535
Y-Mean                                                           0.18                 9.01                 9.51
F-Stat                                                            441                  441                  441
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership and patient health and spending. In
  Panel A, each cell presents the coefficient b obtained by estimating Equation (2) by 2SLS. The independent
  variable is an indicator for the patient being admitted to a PE nursing home, instrumented by differences in
  distance to the nearest PE and non-PE facility. Panel B presents results from a placebo analysis of the
  relationship between private equity ownership and patient health and spending. For this analysis, we use data
  over 2002-07, a period with very little actual PE ownership and which has little overlap with the main
  analysis sample. We assign placebo PE acquisition in 2004 to facilities that were eventually acquired before
  2008 and 2005 to facilities acquired in and post 2008 by PE firms. Accordingly we re-Pcompute differential
  distance values taking into account these placebo acquisitions. We present effects for claims-based patient
  quality outcomes - patient death within 90 days of discharge from the index stay, and total amount billed
  (2016$). All regressions include facility and patient HRR  Year fixed effects, and patient risk controls.
  Patient risk controls include age, race, gender, marital status, indicators for 17 pre-Pexisting conditions
  used to compute the Charlson Index, and an indicator if patients are dual eligible. Standard errors are
  clustered by facility.



               Table 5: Heterogeneity in Patient Mortality
------------------------------------------------------------------------
                   (1)           (2)          (3)           (4)  (Std.
               Observations     Mean      Coefficient        Errors)
------------------------------------------------------------------------
                  A: Patient Level
------------------------------------------------------------------------
1. Age and
 Risk
Low Risk,         2,052,655      0.08          0.0186*          (0.011)
 65-80
High Risk,          881,854      0.24         -0.0346*          (0.021)
 65-80
Low Risk,         3,326,940      0.16        0.0319***          (0.011)
 80+
High Risk,        1,104,387      0.29            0.023          (0.020)
 80+
 
2. Gender
Male              2,640,611      0.21           0.0105          (0.012)
Female            4,725,295      0.14         0.0210**          (0.008)
 
3. Benefici
 ary Zip
 Income
Income <          3,681,687      0.18           0.0122          (0.010)
 Median
Income >          3,684,035      0.16         0.0262**          (0.011)
 Median
 
4. Race
White             6,483,451      0.17        0.0206***          (0.008)
Other               881,923      0.16          -0.0219          (0.023)
 
5. Reason
 for
 hospitaliz
 ation
Cardio-           1,340,956      0.20          0.0298*          (0.016)
 Vascular
Injury            1,409,910      0.11          0.0236*          (0.014)
Other             4,615,012      0.18           0.0096          (0.009)
------------------------------------------------------------------------
                  B: Market Level
------------------------------------------------------------------------
1. Hirfinda
 hl
 Hirschman
 Index
HHI <             3,706,810      0.16           0.0223          (0.020)
 Median
HHI >             3,659,035      0.18          0.0144*          (0.008)
 Median
------------------------------------------------------------------------
Note: This table presents heterogeneity in the effects of PE ownership
  on patient mortality. Column 1 presents the sample size and Column 2
  presents the mean. Columns 3 and 4 present the corresponding
  coefficient b and its standard error obtained by estimating Equation
  (2) by 2SLS. The independent variable is the indicator for a patient
  being admitted to a PE nursing home, instrumented by differences in
  distance to the nearest non-PE and PE nursing home. The outcome
  variable is an indicator for patient death within 90 days of discharge
  from the index stay. Panel A explores heterogeneity on patient level
  factors--by dividing patients into 4 groups based on severity of pre-
  existing co-morbidities (high risk = Charlson Index greater than 2)
  and age (greater than 80) in row 1, gender in row 2, median income in
  the patient's zip code in row 3, race in 4, and the reason for
  hospitalization prior to the nursing home stay in row 5. Panel B
  explores heterogeneity based on market factors--dividing markets below
  and above the median Hirfindahl Hirschman Index (HHI). We computed the
  HHI using market shares in terms of beds as observed in 2003-04, where
  the HRR in which the nursing home is located is considered its market.
  All models include facility and patient HRR  year fixed effects. We
  additionally control for the usual patient risk controls as in the
  main regression. Standard errors are clustered by facility.



                                           Table 6: Patient Well-being
----------------------------------------------------------------------------------------------------------------
                                                   (1)  1(Starts                                    (4) 1(Pain
                                                       Anti-      (2) 1(Mobility  (3) 1(Develops     Intensity
                                                    Psychotics)      Decreases)       Ulcers)       Increases)
----------------------------------------------------------------------------------------------------------------
1(PE)                                                 0.0297***       0.0425***          0.0065         0.0273*
                                                        (0.006)         (0.011)         (0.008)         (0.016)
 
Observations                                          7,365,934       7,365,934       7,365,934       7,365,934
Y-Mean                                                     0.06            0.53            0.09            0.27
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership and measures of patient well-being
  obtained from clinical assessments. Each cell in the first row presents the coefficient b obtained by
  estimating Equation (2). The independent variable is an indicator for the patient being admitted to a PE
  nursing home, instrumented by differences in distance to the nearest PE and non-PE facility. All models
  include facility and patient HRR  Year fixed effects. We additionally control for the usual patient risk
  controls as in the main regression. The independent variable is an indicator for whether a nursing home is
  private  equity-owned (=1 if PE-owned, 0 otherwise) starting in the next year from the deal announcement date.
  We present results for patient level outcomes--an indicator for patient starting anti-psychotics, decrease in
  patient mobility, developing/worsening pressure ulcers, and increase in pain intensity. These variables take
  value one if this condition is not flagged for the patient in the initial assessment, but is flagged at some
  point during the stay. Standard errors are clustered by facility.



                                   Table 7: Patient-Level Analysis: Robustness
----------------------------------------------------------------------------------------------------------------
                                                                           (2) Log Amount       (3) Log Amount
                                                   (1) Mortality (Stay   Billed Per Patient   Billed Per Patient
                                                        + 90 Days)              Stay            Stay + 90 Days
----------------------------------------------------------------------------------------------------------------
1. Base Specification
1(PE)                                               0.0168**  (0.007)   0.1777***  (0.028)   0.1054***  (0.024)
 
2. Chain Controls
1(PE)                                               0.0169**  (0.007)   0.1777***  (0.028)   0.1055***  (0.024)
3. W/O Top 2 Deals
1(PE)                                              0.0309***  (0.011)   0.2309***  (0.045)   0.1429***  (0.037)
4. Top 5 Deals Only
1(PE)                                              0.0349***  (0.012)   0.2469***  (0.046)   0.1510***  (0.039)
5. Only For Profits
1(PE)                                               0.0138**  (0.007)   0.1474***  (0.026)   0.0836***  (0.021)
6. Zip-Year Controls
1(PE)                                               0.0150**  (0.007)   0.1760***  (0.028)   0.1029***  (0.024)
7. HSA-Year FEs
1(PE)                                              0.0211***  (0.008)   0.1800***  (0.030)   0.1130***  (0.025)
8. County-Year FEs
1(PE)                                               0.0221**  (0.010)   0.1430***  (0.034)   0.0832***  (0.029)
9. No Controls
1(PE)                                              0.0296***  (0.008)   0.2391***  (0.030)   0.1131***  (0.024)
 
Observations                                                7,365,934            7,365,934            7,365,934
Y-Mean                                                           0.17                 9.07                 9.57
----------------------------------------------------------------------------------------------------------------
Note: This table presents results from specification checks on the relationship between PE ownership and patient
  health and spending. Each cell presents the coefficient b obtained by estimating Equation (2) by 2SLS. The
  independent variable is an indicator for the patient being admitted to a PE nursing home, instrumented by
  differences in distance to the nearest PE and non-PE facility. We present effects for patient death within 90
  days of discharge from the index stay, the log of the total amount billed for the stay and the log of the
  amount billed for the stay and across hospital inpatient, outpatient and nursing home over the 90 days
  following the stay (2016$). All models include facility fixed effects. The first six rows include HRR  year
  fixed effects, the seventh row uses Health Service Areas (HSA), and the eighth row uses county to define
  patient market instead of HRR. The second row controls for facility being part of a chain. The third row
  calculates the results excluding all data for chains involved in the 2 largest PE deals. The fourth row limits
  the PE group to only the facilities bought in the 5 largest PE deals. The fifth row limits the sample only to
  for-profit facilities. The sixth row includes patient zip controls: median household income, the shares of the
  population that are white, that are renters rather than home-owners, that are below the federal poverty level,
  and that are enrolled in Medicare Advantage program. The first eight rows includes patient risk controls: age,
  race, gender, marital status, indicators for 17 pre-existing conditions used to compute the Charlson score,
  and an indicator if patients are dual eligible. The ninth row presents coefficients from a model with fixed
  effects only. Standard errors are clustered by facility.



                                   Table 8: Mechanisms and Operational Changes
 
----------------------------------------------------------------------------------------------------------------
                                                                  A: Five Star Rating
                                     ---------------------------------------------------------------------------
                                                   (1)                (2)
                                            Deficiency            Overall
                                                Rating             Rating
----------------------------------------------------------------------------------------------------------------
1(PE)                                         -0.075**           -0.079**
(No Control)                                   (0.037)            (0.036)
 
1(PE)                                         -0.077**           -0.082**
(With Control)                                 (0.037)            (0.036)
 
Observations                                   138,051            138,051
Y-Mean                                             2.9                3.2
----------------------------------------------------------------------------------------------------------------
                                                               B: Staff Per Patient Day
                                     ---------------------------------------------------------------------------
                                                   (1)                (2)                (3)                (4)
                                             All Staff    Nurse Assistant     Licensed Nurse   Registered Nurse
----------------------------------------------------------------------------------------------------------------
1(PE)                                        -0.050***          -0.068***          -0.019***           0.037***
(No Control)                                   (0.017)            (0.010)            (0.006)            (0.005)
 
1(PE)                                        -0.048***          -0.066***          -0.019***           0.037***
(With Control)                                 (0.016)            (0.010)            (0.006)            (0.005)
 
Observations                                   283,767            283,767            283,767            283,767
 
Y-Mean                                             3.6                2.3                0.8                0.5
----------------------------------------------------------------------------------------------------------------
                                                                   C: Log Financials
                                     ---------------------------------------------------------------------------
                                                   (1)                (2)                (3)                (4)
                                        Management Fee     Building Lease   Interest Expense                   Cash on Hand
----------------------------------------------------------------------------------------------------------------
1(PE)                                          0.074**           0.564***           1.181***          -0.322***
(No Control)                                   (0.032)            (0.061)            (0.096)            (0.042)
 
1(PE)                                          0.074**           0.560***           1.175***          -0.318***
(With Control)                                 (0.032)            (0.061)            (0.096)            (0.042)
 
Observations                                   231,556            231,584            231,613            231,569
Y-Mean                                             0.2                0.4                0.3               11.2
----------------------------------------------------------------------------------------------------------------
 
Note: This table presents estimates of the relationship between PE ownership and nursing home outcomes. Each
  cell presents the coefficient b obtained by estimating equation 9 with a different outcome. The independent
  variable is an indicator for whether a nursing home is PE-owned (=1 if PE-owned, 0 otherwise) starting in the
  next year from the deal announcement date. Panel A presents results for quality outcomes as measured by Five-
  star rating awarded by CMS - overall rating and deficiencies identified by independent contractors in audits,
  respectively. A negative effect on ratings implies a decline in quality. Panel B presents results on per
  patient nurse availability for all nurses, nurse assistants, licensed nurses, and registered nurses. Panel C
  presents results on the log of management fees, building lease cost, interest expenses, and cash on hand. The
  top row presents results with no controls. The bottom row presents the results including controls, which
  consist of market-level and patient mix controls, as described in Section 6.1. All models include facility and
  year fixed effects. All variables are winsorized at 1% and 99% levels. Standard errors are clustered by
  facility.

                    Appendix: For Online Publication

A Data appendix

This paper uses three primary data sources. We use (1) publicly 
available nursing home-level data, (2) patient-level administrative 
claims data, both obtained from CMS, and (3) Pitchbook data on PE 
deals. This section provides a detailed explanation of these data 
sources and how we arrived at our analysis samples.

A.1 Nursing Home Data

Our data source on nursing home-level operations and performance is a 
compilation of information obtained during annual surprise CMS 
inspector audits and data on nursing home attributes and patient 
characteristics reported by the facilities themselves.\33\ The data 
span 2000 through 2017. In each year we observe about 15,000 unique 
nursing homes, for a total of approximately 280,000 observations. Of 
these, about 29,000 observations represent facilities acquired by PE 
firms. The aggregate files provide annual data on basic facility 
attributes, patient volume and case mix, nurse availability, and 
various components of the Five Star ratings.\34\ These ratings started 
in 2009, so we cannot observe ratings pre-buyout for deals before 2010. 
Fortunately, half of the PE deals in our sample, accounting for 365 
nursing homes, occurred post-2009.
---------------------------------------------------------------------------
    \33\ These files were organized and made available for research by 
the Long Term Care Focus research center at Brown University. See 
www.ltcfocus.org for more details.
    \34\ For more details on how the ratings are produced, see Rating 
Guide.

    Table 1 Panel A presents summary statistics on the Overall Five 
Star rating as well as the other key nursing home-level variables used 
in the analysis. We first present the mean and standard deviation for 
the whole sample (columns 1-2), then divide observations into two 
groups--for facilities that are not PE-owned (columns 4-5) and for 
those that are (columns 6-7). We observe clear differences between PE-
owned facilities and those not owned (all statistically significant at 
the 1% level except where noted). PE targets are slightly larger, have 
fewer staff hours per resident, and a lower Overall Five Star rating. 
There have been secular increases for the whole sector in both ratings 
and staffing over time. For staffing, this reflects more stringent 
standards from regulators over time. Average staff hours per patient 
day increased from 3.5 in 2000 to 3.7 in 2017. Similarly, overall 
average Five Star ratings increased from 2.9 in 2009 to 3.25 in 2017. 
As the PE deals occurred primarily later in the sample, it is therefore 
remarkable that they have lower measures of quality on average.

A.2 Patient Data

Our second data source consists of patient-level billing claims and 
assessment data for Medicare fee-for-service beneficiaries from 2004 to 
2016. We observe the universe of billing data for hospital care 
(inpatient and outpatient) and nursing homes for these beneficiaries, 
as well as detailed patient assessments recorded in the Minimum Data 
Set (MDS).\35\ We use these files to track beneficiaries' demographics, 
spending, and health outcomes such as mortality. The MDS helps observe 
clinical assessments such as mobility and the use of antipsychotic 
drugs.
---------------------------------------------------------------------------
    \35\ Specifically, we use 100% samples of the following: Medicare 
Beneficiary Summary File (MBSF), Hospital inpatient and outpatient, and 
Skilled Nursing Facility claims files. These were obtained through a 
reuse DUA with CMS and accessed through the NBER.

    The unit of observation is a nursing home stay for a Medicare 
beneficiary that begins during our sample period, which we begin in 
2005 in order to have at least one look-back year. Our main sample 
restriction is to identify index nursing home stays for patients, 
defined as stays that begin at least a year after discharge from a 
previous nursing home stay. This helps avoid mis-attributing adverse 
effects to the wrong nursing home. To further avoid attribution error, 
we consider only the patient's first index stay in our entire sample 
period. Hence, each patient appears only once in our sample. Using this 
approach, we settle on a sample of more than seven million patients 
over 12 years. For each of these patients, we also observe clinical 
assessments from the MDS, which we successfully match to the claims 
files. Following the prior literature (Grabowski, Feng, Hirth, Rahman 
and Mor, 2013), we use some other restrictions to arrive at our sample. 
We restrict to patients over 65 years of age who are enrolled in 
Medicare parts A and B for at least 12 months before the start of the 
nursing home stay. This restriction ensures that we observe prior 
medical care history and pre-existing conditions. We also restrict to 
stays associated with a hospital visit in the previous month, so that 
all patients are admitted after a hospital-based procedure and are 
relatively homogeneous. We drop patients who went to a nursing home in 
a state other than their state of residence as recorded in the Medicare 
master beneficiary summary file. This drops a small fraction of 
patients (less than 5%) and is meant to exclude patients who may be 
traveling when admitted to a nursing home. We match the index nursing 
home stays to the MDS sample on beneficiary ID, facility ID, and 
admission date. We achieve a match rate of 94% and drop unmatched 
patients. We drop facilities with fewer than 100 patients over the 
---------------------------------------------------------------------------
entire sample period to avoid special facilities and mitigate noise.

    Table 1 Panel B presents summary statistics on the final patient-
level sample. We use an indicator for death within 90 days following 
discharge (including during the stay), based on death dates recorded in 
the Medicare master beneficiary summary file. We use two measures of 
spending. The first is the total amount that the nursing home bills to 
Medicare and the patient for the index stay in 2016 dollars. Medicare 
covers the entire cost until the 21st day of stay, at which point the 
patient begins paying a coinsurance, which has risen somewhat over time 
and is now $170.5 per day.\36\ In our data, about 90% of total payments 
are by Medicare. PE-owned facilities charge about 10% more than other 
facilities. The second measure is the total amount paid for the stay 
and the 90 days following discharge. This captures any subsequent 
hospital inpatient or outpatient care, and it provides a more holistic 
picture of patient care.
---------------------------------------------------------------------------
    \36\ See https://www.resdac.org/cms-data/files/ip-ffs/data-
documentation and https://www.
medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf.

    Demographic measures associated with risk are quite similar across 
the types of facilities, including patient age, the share of patients 
who are black and married, and the Charlson Comorbidity Index, a 
standard measure of patient mortality risk based on co-morbidities 
(Charlson, Szatrowski, Peterson and Gold, 1994).\37\ We create a high-
risk indicator that is one if the previous-quarter Charlson score is 
greater than two. According to this definition, about 30% of patients 
are high-risk. The difference between facility types is not 
significant.
---------------------------------------------------------------------------
    \37\ The ``Charlson score'' assigns a point score to each of 17 
disease categories recorded during the 3 months before the index stay 
and sums them to create an overall disease burden score.

    Finally, we examine four measures of patient well-being which 
comprise inputs to the quality portion of CMS' Five Star ratings. The 
first is an indicator for the patient starting antipsychotic medication 
during the stay. The second is an indicator for the patient's self-
reported mobility score declining during the stay. The third is an 
indicator for developing a pressure ulcer. The fourth is an indicator 
for the patient's self-reported pain intensity score increasing during 
the stay.

A.3 PE Deal Data

    Our primary source of data on PE transactions is a proprietary list 
of deals in the ``Elder and disabled care'' sector compiled by 
Pitchbook Inc., a leading market intelligence firm in this space. The 
deals span 2004 to 2015. We match the target names to individual 
nursing facilities using name (facility or corporate owner) and address 
as recorded in CMS data.\38\ Target names in these deals typically 
refer to holding companies, which often do not reflect the names of 
individual facilities. The matching process required manual Internet 
searches to confirm chain affiliations. We supplement the Pitchbook 
data in two ways. First, we conduct additional Internet searches that 
yielded a small number of PE deals not reported by Pitchbook. Second, 
we obtain a list of merger and acquisition deals from 2005 to 2016 from 
Levin Associates, a market intelligence firm that tracks the healthcare 
sector. This helps us to identify facilities that did not experience a 
new PE deal, but were acquired by an existing PE-owned chain.\39\
---------------------------------------------------------------------------
    \38\ We obtain data on nursing home attributes (name, address, 
city, owner name and type, number of beds) and quality measures 
(deficiencies) from Nursing Home Compare. See https://
data.medicare.gov/data/nursing-home-compare for more details.
    \39\ We matched approximately 290 additional facilities using 
information from the Levin files to the CMS data. Of these, about 40 
were PE-owned.

    This process yielded 128 deals, which correspond to a change in 
ownership to PE for 1,674 facilities. The deals are spread over time 
(no particular year or part of the business cycle dominates) and across 
PE firms. Figure B.1 shows the number of deals in each year. In total, 
our data contain 136 unique PE firms that acquired nursing homes. Most 
deals are syndicated and involve multiple PE firms. Table B.1 presents 
the top 10 deals by number of facilities acquired. Deal sizes are 
skewed, with the top 10 deals accounting for about 80% of all 
facilities acquired. On average, we observe PE-owned facilities for 
eight years post-acquisition.\40\
---------------------------------------------------------------------------
    \40\ A likely source of measurement error is not capturing PE 
disinvestment from facility ownership. For the top 10 deals (80% of 
facilities) we verified PE exit via manual Internet searches and 
incorporated it in the analysis. The main results are robust to 
dropping observations of facilities that have been owned by PEs for 10 
years or more. As expected, the coefficients modestly increase in 
magnitude when we do so.

    It is difficult to ascertain whether we comprehensively capture PE 
activity in this sector. While there is no ``official'' tally of PE-
owned nursing homes to benchmark against, our sample size compares 
favorably against an estimate of 1,876 nursing homes reportedly 
acquired by PE firms over a similar duration, 1998-2008 (GAO, 2010). 
Nonetheless, our analysis likely underestimates the extent of PE 
activity in nursing homes, as matching between Pitchbook deals and 
---------------------------------------------------------------------------
individual facilities is very challenging.

    To understand whether deals are concentrated in particular regions, 
we plot the location of PE-owned facilities across the U.S. in Figure 
B.2. PE firms appear to be more active in large metropolitan markets, 
and in certain states such as Florida, Texas, New York, Pennsylvania 
and Massachusetts. However, there is no obvious concentration, and we 
do not find systematic variation with local measures of income, age, 
elder population, or share of patients eligible for Medicare Advantage.

A.4 Targeting

This paper does not address why nursing homes may or may not be 
profitable acquisition targets, and does not assess returns from 
investing. However, exploring what types of facilities are targeted can 
help to interpret the effects of buyouts on patient welfare and is also 
useful for identifying the most relevant control variables for our 
empirical analysis. We describe which characteristics are robustly 
associated with buyouts in Table A.1, which presents estimates of 
Equation (11):

[GRAPHIC] [TIFF OMITTED] T1721.016


.epsHere, PEj,t is set to 100 if the facility j is acquired 
in a PE deal in year t (we drop all years post-deal, and multiply by 
100 for ease of reading). PEj,t is zero for never-PE and PE-
owned facilities before the deal. We include state and year fixed 
effects.

    We report models including variables known to be central to nursing 
home quality of care and economics or that are potentially important 
and robustly predict buyouts. In column 1, we find that facilities in 
more urban counties are more likely to be targeted.\41\ Urban nursing 
homes tend to be closer to hospitals and likely enjoy thicker labor 
markets. Facilities in a state with a higher ratio of elderly people 
are also more likely to be targeted. County-level income, race, and 
home ownership do not predict buyouts. Results for these covariates are 
not presented.
---------------------------------------------------------------------------
    \41\ We define urban as being in the top 2 out of 9 county groups 
classified as urban based on a Department of Housing and Urban 
Development 2003 rural-urban classification.

    In column 2, we turn to facility characteristics. Chains are more 
likely to be acquired than independent facilities, likely reflecting 
substantial fixed costs in deal-making. Hospital-owned facilities are 
less likely to be targeted. PE firms also tend to target larger and 
higher-occupancy facilities. We consider patient-level characteristics 
in column 3: the share of the nursing home's patients covered by 
Medicaid, the share on private insurance, and the share who are Black. 
The first two are strongly negatively associated with buyouts, meaning 
that a higher share of Medicare patients (the omitted group) is 
positively associated with being targeted. In column 4, we assess two 
facility-level quality measures we employ in the analysis: Five Star 
overall rating and staff hours per patient day. Both are negatively 
associated with buyouts, but once we control for rating, staffing is 
not significant. These results indicate that PE firms target relatively 
---------------------------------------------------------------------------
low-performing nursing homes.

    Finally, in column 5 we include simultaneously all of the variables 
from the previous models that had predictive power. Some, such as 
admits per bed and hospital ownership, become small and insignificant 
after controlling for the other variables. Notably, the state elder 
ratio, chain indicator, and Five star rating retain their magnitudes 
and precision.


                                              Table A.1: Targeting
----------------------------------------------------------------------------------------------------------------
                                          Mean       (1)          (2)          (3)          (4)          (5)
----------------------------------------------------------------------------------------------------------------
Urban Indicator                           0.56     0.193***                                             0.105**
                                                    (0.037)                                             (0.041)
 
State Elder Ratio                         0.24     4.340***                                           18.819***
                                                    (1.328)                                             (3.906)
 
1(Chain)                                  0.53                  0.835***                               0.367***
                                                                 (0.033)                                (0.029)
 
Hospital-Owned                            0.07                 -0.221***                                 -0.003
                                                                 (0.053)                                (0.067)
 
Log (Beds)                                 4.5                  0.287***                               0.086***
                                                                 (0.030)                                (0.032)
 
Admits Per Bed                            2.08                  0.051***                                  0.009
                                                                 (0.007)                                (0.015)
 
Ratio Medicaid                            0.60                              -0.879***                   -0.434*
                                                                              (0.117)                   (0.229)
 
Ratio Private                             0.25                              -1.441***                   -0.422*
                                                                              (0.144)                   (0.236)
 
Ratio Black                               0.10                                  0.002
                                                                              (0.099)
 
Overall Rating                            3.15                                           -0.075***    -0.066***
                                                                                           (0.015)      (0.015)
 
Staff Hr per Patient Day                  3.55                                              -0.022
                                                                                           (0.018)
 
Observations                                        235,670      218,592      218,592      103,831      103,831
Y-Mean (pp)                                             0.6          0.6          0.6          0.6          0.6
----------------------------------------------------------------------------------------------------------------
Note: This table shows estimates of the relationship between pre-existing nursing home characteristics and
  whether a nursing home is a target of a PE buyout. Column 1 presents market-level attributes: an indicator for
  urban and the share of state population which is elderly. Column 2 presents facility-level attributes:
  indicator for being member of a chain, indicator for the nursing home being hospital-based, the log number of
  beds, and admits per bed. Column 3 presents patient mix controls: share of patients covered by Medicaid, share
  of patients who pay privately, and the share of patients who are black. Column 4 presents quality metrics such
  as Five-star ratings awarded by CMS and staff hours per patient day. We re-run the regression on all variables
  which appear significant in Columns 1 to 4 in Column 5. The dependent variable is 100 if the nursing home was
  acquired by PE in that year and 0 otherwise. We remove all observations of private equity-owned facilities in
  years following the take-over by PE. We control for state and year FEs. Standard errors are clustered by
  facility.

B Supplementary Figures and Tables
[GRAPHIC] [TIFF OMITTED] T1721.017


    .eps Note: This figure presents the number of unique deals for 
active nursing homes by PE firms for each year over the period 2004-
2015.

[GRAPHIC] [TIFF OMITTED] T1721.018


    .eps Note: This figure presents the number of facilities bought by 
PE firms in each county over the period 2004-2015. We identified 1,674 
such facilities.

[GRAPHIC] [TIFF OMITTED] T1721.019


    .eps Note: This figure presents event studies on initial patient 
assessments around the time a nursing home experiences a PE buyout. To 
match the event study plots presented in the main text, we estimate 
these models on collapsed facility-year level data and use the same 
specification, i.e., facility and year fixed effects, patient mix, and 
market controls, as described in Section 6.1. Each point in the figures 
represents the coefficient bs obtained by estimating 
Equation (10) as discussed in Section 6. Year = -2 is the omitted 
point. Panel A presents results on the share of patients diagnosed with 
Dementia, Panel B on Alzheimers, Panel C on Hip Fractures, and Panel D 
on Urinary Tract Infections, respectively, at admission to the index 
nursing home stay. Standard errors are clustered by facility.

[GRAPHIC] [TIFF OMITTED] T1721.020


    .eps Note: This figure provides descriptes on patient zip code 
distance to index nursing home zip code. Panels A and B present CDFs of 
the distance from patient zip code to index nursing home zip code. 
Panel A presents the CDF pooling PE and non-PE patients together. It 
also identifies the median, 75th and 90th percentile values. Panel B 
presents the CDFs separately for PE and non-PE patients, and their 
respective median values. Panel C presents the annual trendline for the 
share of patients going to their closest nursing home. Panel D presents 
the event study of the mean patient distance around a PE acquisition. 
Each point in the figure represents the coefficient bs 
obtained by estimating Equation (10) as discussed in Section 6. Year = 
-2 is the omitted point. The model includes facility and HRR  year 
fixed effects, patient mix, and market controls. Standard errors are 
clustered by facility.

[GRAPHIC] [TIFF OMITTED] T1721.021


    .eps Note: This figure presents event studies on patient outcome 
measures around the time a nursing home experiences a PE buyout. To 
match the event study plots presented in the main text, we estimate 
these models on collapsed facility-year level data and use the same 
specification, i.e., facility and year fixed effects, patient mix, and 
market controls, as described in Section 6.1. Each point in the figures 
represents the coefficient bs obtained by estimating 
Equation (10) as discussed in Section 6. Year = -2 is the omitted 
point. Panels A and B present results on the share of patients dying 
within 90 days of discharge from the index stay, and total amount 
billed over the 90-day episode including the index stay (2016$). Panels 
C to F present results for MDS assessment based outcomes--the facility 
level mean for indicators for patient starting antipyschotics, decrease 
in patient mobility, developing/worsening pressure ulcers, and increase 
in pain intensity respectively. Spending is winsorized at the 1% and 
99% level. Standard errors are clustered by facility.

[GRAPHIC] [TIFF OMITTED] T1721.022


    .eps Note: This figure presents additional plots pertaining to 
Marginal Treatment Effects (MTE) analysis using the Medicare patient-
level data. Panel A presents the overlap in distributions of PE and 
non-PE groups by propensity score, using a linear scale for the Y-axis. 
Panel B demonstrates robustness of the slope of the MTE curve to using 
different orders of polynomials. Section 5.2.2 presents details of the 
MTE estimation.

[GRAPHIC] [TIFF OMITTED] T1721.023


    .eps Note: This figure presents scatter plots of changes in total 
staff hours available per patient day in the three years post-PE buyout 
versus three years pre-buyout on the X-axis, against changes in CMS 
Five-star rating over the same period on the Y-axis. Panel A presents 
overall rating, and Panel B presents survey based deficiency ratings. 
The data was collapsed into 20 equal sized bins and we plot the means 
in each bin. The figures also present fitted lines for these plots 
obtained using linear regressions on the underlying data. Each plot 
also presents the slope coefficient with standard error.

[GRAPHIC] [TIFF OMITTED] T1721.024


    .eps Note: This figure presents event studies on facility 
characteristics around the time a nursing home experiences a PE buyout. 
Each point in the figures represents the coefficient bs 
obtained by estimating Equation (10) as discussed in Section 6. Year = 
-2 is the omitted point. Panels A and B present results on the log of 
beds and admissions at the facility level, and Panel C on log 
admissions at the market level (HRR). All models--except when studying 
market-level volume--include facility and year fixed effects, patient 
mix, and market controls, as described in Section 6.1. All dependent 
variables are winsorized at 1% and 99% levels. Standard errors are 
clustered by facility.


                 Table B.1: Top 10 Private Equity Deals
------------------------------------------------------------------------
 Sr.                       Private Equity                     Number of
 No.     Target Name          Firm(s)           Deal Year    Facilities
------------------------------------------------------------------------
   1   Genesis         Formation Capital,         2007-15           327
        Healthcare      JER Partners
   2   Golden Living   Fillmore Capital              2006           321
                        Partners
   3   Kindred         Signature Healthcare,         2014           150
        Healthcare      Hillview Capital
   4   HCR Manorcare   Stockwell Capital,         2007-18           145
                        The Carlyle Group
   5   Mariner         Fillmore Capital              2004            95
        Healthcare      Partners
   6   Skilled         Onex, Heritage             2005-07            76
        Healthcare      Partners
        Group
   7   Trilogy         Lydian Capital             2007-15            65
        Investors       Partners
   8   Lavie Care      Formation Capital,            2011            61
        Centers         Senior Care
                        Development
   9   Laurel Health   Formation Capital,         2006-16            41
        Care Company    Longwing Real Estate
                        Ventures
  10   Harden          NXT Capital, Oaktree          2013            35
        Healthcare      Speciality Lending
------------------------------------------------------------------------
Note: This table presents some details on the top 10 PE deals in our
  sample, ordered by the number of unique nursing home facilities
  involved in the deal. This represents the number of facilities we were
  able to identify and match in our administrative data, the actual
  number of facilities in the deal may have been different. We set the
  PE indicator to turn on in the year following the deal year. If a
  closing year is mentioned, it implies the PE investors exited or went
  public in that year. Accordingly, we turn off the PE indicator in the
  closing year.



                                       Table B.2: Complier Characteristics
----------------------------------------------------------------------------------------------------------------
                                                   Observations     Coefficient    (Std. Errors)       Ratio
----------------------------------------------------------------------------------------------------------------
Full Sample                                           7,365,934      -0.0445***         (0.003)
 
A. Age and Risk
Low Risk, 65-80                                       2,052,655      -0.0405***         (0.002)            0.91
High Risk, 65-80                                        881,854      -0.0471***         (0.003)            1.06
Low Risk, 80+                                         3,326,940      -0.0451***         (0.003)            1.01
High Risk, 80+                                        1,104,387      -0.0478***         (0.003)            1.07
 
B. Gender
Male                                                  2,640,611      -0.0456***         (0.003)            1.02
Female                                                4,725,295      -0.0439***         (0.003)            0.99
 
C. Marital Status
Unmarried                                             4,838,365      -0.0446***         (0.003)            1.00
Married                                               2,527,548      -0.0439***         (0.003)            0.99
 
D. Beneficiary Zip Income
Income < Median                                       3,681,687      -0.0554***         (0.004)            1.24
Income > Median                                       3,684,035      -0.0353***         (0.003)            0.79
 
E. Race
White                                                 6,483,451      -0.0451***         (0.003)            1.01
Other                                                   881,923      -0.0380***         (0.003)            0.85
----------------------------------------------------------------------------------------------------------------
Note: This table presents first stage equivalent estimates of the 2SLS for various patient subsamples. We
  present the coefficient b, obtained by estimating the equation PEi = aj + am,t + b 1(DDi > Median) + ei. 1(DDi
  > Median) is an indicator for patient i's differential distance to the nearest PE-owned facility being greater
  than the median value. The model includes facility j and patient HRR  year fixed effects, but no other
  controls. We divide the sample by age and risk, gender, marital status, income in patient zip code, and race.
  Details are available in Section 4.2. We also present the ratio of the coefficient obtained for each subsample
  to that for the full sample. Standard errors are clustered by facilities.



                                    Table B.3: Mortality Effects by Duration
----------------------------------------------------------------------------------------------------------------
                                   (1)  (Stay + 30    (2)  (Stay + 60    (3)  (Stay + 90      (4)  (Stay + 365
                                        Days)              Days)              Days)                Days)
----------------------------------------------------------------------------------------------------------------
1(PE)                                        0.009           0.0148**           0.0169**              0.0239***
                                           (0.006)            (0.007)            (0.007)                (0.008)
 
Observations                             7,365,934          7,365,934          7,365,934              7,365,934
Y-Mean                                        0.12               0.15               0.17                   0.24
F-Stat                                       223.9              223.9              223.9                  223.9
Coefficient/PY-Mean                             8%                10%                10%                    10%
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership and patient mortality. Each cell
  presents the coefficient b obtained by estimating Equation (2) by 2SLS. The independent variable is an
  indicator for the patient being admitted to a PE nursing home, instrumented by differences in distance to the
  nearest PE and non-PE facility. We present effects for mortality at different durations--patient death within
  30, 60, 90, and 365 days of discharge from the index stay. All regressions include facility and patient HRR 
  year fixed effects, and patient risk controls. Patient risk controls include age, race, gender, marital
  status, indicators for 17 pre-existing conditions used to compute the Charlson Index, and an indicator for
  dual eligibility. Standard errors are clustered by facility.



                       Table B.4: Mortality Costs
------------------------------------------------------------------------
                                           (1)  Male       (2)  Female
------------------------------------------------------------------------
A: IV estimates
1(PE)                                           0.0105         0.0210**
                                               (0.012)          (0.008)
 
Observations                                 2,640,611        4,725,295
Y-Mean                                            0.21             0.14
F-Stat                                             221              221
------------------------------------------------------------------------
B: Placebo
1(PE)                                           0.0091           0.0044
                                               (0.006)          (0.005)
 
Observations                                 2,497,830        4,661,700
Y-Mean                                            0.23             0.15
F-Stat                                             431              440
------------------------------------------------------------------------
C: Calculations
Number of Patients in PE Facilities            435,035          741,838
Additional Deaths                                4,568           15,579
------------------------------------------------------------------------
    Total Lives Lost                                             20,146
 
Mean Life Expectancy                               6.7              8.2
Additional Loss in Person Years                 30,814          128,384
------------------------------------------------------------------------
    Total Person Years Lost                                     159,198
    Value of Life Year (2016$)                                  130,000
    Total Cost (2016$)                                     20.7 Billion
------------------------------------------------------------------------
Note: This table presents estimates of additional deaths, life-years
  lost, and the associated cost using standard estimates of statistical
  value of a life-year due to PE ownership of nursing homes. Panel A
  presents the coefficient b obtained by estimating Equation (2) by
  2SLS. The independent variable is the indicator for a patient being
  admitted to a PE nursing home, instrumented by differences in distance
  to the nearest non-PE and PE nursing home. The outcome variable is an
  indicator for patient death within 90 days of discharge from the index
  stay. Panel B presents a placebo analysis for this patient subsample
  using the same approach as for the whole sample, as presented in Table
  4. All models include facility and patient HRR - year fixed effects
  and the usual patient risk controls as in the main specification.
  Standard errors are clustered by facility. Panel C presents
  calculations to estimate lives, life-years lost and total cost based
  on Panel A coefficients. We calculate average life expectancy at
  discharge (by gender) using the observed distribution of lifespans for
  Medicare patients. For patients still alive at the end of our sample,
  we assign a year of death based on patient gender and age using Social
  Security actuary tables. We adjust downward the resulting life
  expectancy to account for the fact the decedents tend to be older than
  the average nursing home patient (about two years).



                                 Table B.5: Patient-Level Analysis: OLS Results
 
----------------------------------------------------------------------------------------------------------------
                                                             A: Initial Patient Assesments
----------------------------------------------------------------------------------------------------------------
                                                   (1)                (2)                (3)                (4)
                                              Dementia         Alzheimers       Hip Fracture      Urinary Tract
                                          at Admission       at Admission       at Admission          Infection
                                                                                                   at Admission
----------------------------------------------------------------------------------------------------------------
1(PE)                                       -0.0098***         -0.0040***         -0.0034***           0.0044**
                                               (0.002)            (0.001)            (0.001)            (0.002)
 
Observations                                 7,365,934          7,365,934          7,365,934          7,365,934
Y-Mean                                            0.16               0.05               0.09               0.16
----------------------------------------------------------------------------------------------------------------
                                                                   B: Main Outcomes
----------------------------------------------------------------------------------------------------------------
                                                   (1)                (2)                (3)
                                             Mortality   Log Amount Billed  Log Amount Billed
                                      (Stay + 90 Days)                Per                Per
                                                             Patient Stay   Patient Stay + 90
                                                                                        Days
----------------------------------------------------------------------------------------------------------------
1(PE)                                        0.0034***         -0.0221***          -0.0118**
                                               (0.001)            (0.006)            (0.005)
 
Observations                                 7,365,934          7,365,934          7,365,934
Y-Mean                                            0.17               9.07               9.57
----------------------------------------------------------------------------------------------------------------
                                                              C: Assesment Based Outcomes
----------------------------------------------------------------------------------------------------------------
                                                   (1)                (2)                (3)                (4)
                                        1(Starts Anti-         1(Mobility         1(Develops   1(Pain Intensity
                                           Psychotics)         Decreases)            Ulcers)         Increases)
----------------------------------------------------------------------------------------------------------------
1(PE)                                        0.0115***          0.0349***          0.0094***          0.0266***
                                               (0.001)            (0.003)            (0.003)            (0.005)
 
Observations                                 7,365,934          7,365,934          7,365,934          7,365,934
Y-Mean                                            0.06               0.53               0.09               0.27
----------------------------------------------------------------------------------------------------------------
Note: This table presents OLS estimates of the relationship between PE ownership and patient health and
  spending. Each cell presents the coefficient b obtained by estimating Equation (2) by OLS. The independent
  variable is an indicator for the patient being admitted to a PE nursing home. In Panel A, we present effects
  for initial patient assessments--dementia, alzheimers, hip fracture and urinary tract infection at time of
  admission. In Panel B, we present effects on patient death within 90 days of discharge from the index stay and
  total amount billed during the stay and during the 90 day episode (2016$). Panel C presents results for
  assessment based outcomes recorded in the MDS--an indicator for patient starting antipyschotics, decrease in
  patient mobility, developing/worsening pressure ulcers, and increase in pain intensity. All regressions
  include facility and patient HRR x Year fixed effects, and patient risk controls. Patient risk controls
  include age, race, gender, marital status, indicators for 17 pre-existing conditions used to compute the
  Charlson Index, and an indicator for dual eligibility. Standard errors are clustered by facility.



                                 Table B.6: Robustness: Facility-Level Outcomes
 
----------------------------------------------------------------------------------------------------------------
                                                                    A: Five Star Rating
                                         -----------------------------------------------------------------------
                                                      (1)               (2)
                                               Deficiency           Overall
                                                   Rating            Rating
----------------------------------------------------------------------------------------------------------------
1. Chain Controls
1(PE)                                            -0.074**          -0.079**
                                                  (0.036)           (0.028)
 
2. W/O Top 2 Deals
1(PE)                                           -0.145***         -0.204***
                                                  (0.050)           (0.042)
 
3. Only For Profit
1(PE)                                            -0.077**          -0.082**
                                                  (0.036)           (0.028)
 
Observations                                      138,051           138,051
Y-Mean                                                2.9               3.2
----------------------------------------------------------------------------------------------------------------
                                                                 B: Staff Per Patient Day
                                         -----------------------------------------------------------------------
                                                      (1)               (2)               (3)               (4)
                                                All Staff   Nurse Assistant    Licensed Nurse   Registered Nurse
----------------------------------------------------------------------------------------------------------------
1. Chain Controls
1(PE)                                           -0.050***         -0.068***         -0.019***          0.037***
                                                  (0.016)           (0.010)           (0.006)           (0.005)
2. W/O Top 2 Deals
1(PE)                                           -0.100***         -0.101***          -0.021**          0.030***
                                                  (0.026)           (0.015)           (0.009)           (0.008)
3. Only For Profit
1(PE)                                           -0.045***         -0.062***         -0.024***          0.039***
                                                  (0.017)           (0.010)           (0.006)           (0.005)
 
Observations                                      283,767           283,767           283,767           283,767
Y-Mean                                                3.6               2.3               0.8               0.5
----------------------------------------------------------------------------------------------------------------
                                                                     C: Log Financials
                                         -----------------------------------------------------------------------
                                                      (1)               (2)               (3)               (4)
                                           Management Fee    Building Lease   Interest Expense                 Cash on Hand
----------------------------------------------------------------------------------------------------------------
1. Chain Controls
1(PE)                                             0.074**          0.564***          1.181***         -0.321***
                                                  (0.032)           (0.061)           (0.096)           (0.042)
2. W/O Top 2 Deals
1(PE)                                               0.042          0.809***          2.048***         -0.366***
                                                  (0.050)           (0.102)           (0.160)           (0.068)
3. Only For Profit
1(PE)                                              0.056*          0.570***          1.179***         -0.289***
                                                  (0.032)           (0.061)           (0.096)           (0.043)
 
Observations                                      231,556           231,584           231,613           231,569
Y-Mean                                                0.2               0.4               0.3              11.2
----------------------------------------------------------------------------------------------------------------
Note: This table presents robustness tests on the estimates of the relationship between PE buyouts and Five star
  ratings, nurse availability, and financials. The corresponding main results are presented Table 8. Each cell
  presents the coefficient b obtained by estimating Equation (9) with a different outcome. The independent
  variable is an indicator for whether a nursing home is PE-owned (=1 if PE-owned, 0 otherwise) starting in the
  next year from the deal announcement date. We control for a chain indicator in the first row, remove the top 2
  deals by size in the second row, and estimate the results on a sample limited to for-profit facilities in the
  third row. We do not present results limiting to the Top 5 deals as Five Star ratings are only available post-
  2009, and 4 Top 5 deals occurred before 2009. All models include facility and year fixed effects. All
  variables are winsorized at 1% and 99% levels. Standard errors are clustered by facility.



                        Table B.7: Patient Volume
------------------------------------------------------------------------
                                Facility Level             Market Level
                      --------------------------------------------------
                                            (2)  Log         (3)  Log
                        (1)  Log  Beds     Admissions       Admissions
------------------------------------------------------------------------
1(PE)                          -0.002         0.036***            0.014
(No Control)                  (0.003)          (0.009)          (0.014)
 
1(PE)                          -0.003         0.035***            0.007
(With Control)                (0.003)          (0.009)          (0.011)
 
Observations                  283,767          283,767            5,364
Y-Mean                            4.5              4.8             12.7
------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE
  ownership and patient volume. Each cell presents the coefficient b
  obtained by estimating Equation (9) with a different outcome. The
  independent variable is an indicator for whether a nursing home is PE-
  owned (=1 if PE-owned, 0 otherwise) starting in the next year from the
  deal announcement date. We present results on the log number of beds,
  log number of admissions in facility, and log number of admissions at
  HRR level. The bottom row presents the results including controls,
  which consist of market-level and patient mix controls, as described
  in Section 6.1. All models include facility and year fixed effects.
  All variables are winsorized at 1% and 99% levels. Standard errors are
  clustered by facility.


                                 ______
                                 

                     Congress of the United States

                          Washington, DC 20510

                            November 15,2019

Kewsong Lee
Co-Chief Executive Officer
The Carlyle Group
1001 Pennsylvania Avenue, NW
Washington, DC 20004-2505

Glenn A. Youngkin
Co-Chief Executive Officer
The Carlyle Group
1001 Pennsylvania Avenue, NW
Washington, DC 20004-2505

Dear Messrs. Lee and Yonugkin:

We are writing to request information regarding the Carlyle Group's 
(Carlyle) investment in companies providing nursing home care and other 
long-term care services and to request information about your firm's 
structure and finances as it relates to these companies.

Private equity funds often operate under a model where they purchase 
controlling interests in companies for a short time, load them up with 
debt, strip them of their assets, extract exorbitant fees, and sell 
them at a profit--implementing drastic cost-cutting measures at the 
expense of consumers, workers, communities, and taxpayers. For that 
reason, we have concerns about the rapid spread and effect of private 
equity investment in many sectors of the economy, especially industries 
that affect vulnerable populations and rely primarily on taxpayer-
funded programs such as Medicare and Medicaid, like the nursing home 
industry. We are particularly concerned about your firm's investment in 
large for-profit nursing home chains, which research has shown often 
provide worse care than not-for-profit faci1ities.\1\ In light of these 
concerns, we request information about your firm, the portfolio 
companies in which it has invested, and the performance of those 
investments.
---------------------------------------------------------------------------
    \1\ International Journal of Health Services, ``Ownership, 
Financing, and Management Strategies of the 10 largest for-profit 
nursing home chains in the United States,'' Charlene Harrington et al., 
2011, https://www.ncbi.nlm.nih.gov/pubmed/22053531; Kaiser Family 
Foundation, ``Reading the Stars: Nursing Home Quality Star Ratings, 
Nationally and by State,'' May 2015, http://files.kff.org/attachment/
issue-brief-reading-the-stars-nursing-home-quality-star-ratings-
nationally-and-by-state.

Nursing homes provide a wide range of important medical and personal 
care services to a growing and vulnerable elderly population, with 1.3 
million residents in the United States currently receiving care in more 
than 15,000 facilities.\2\ For decades, reports and data have 
highlighted the shocking living conditions found in many nursing home 
and other long-term care facilities across the country.\3\ Twelve years 
ago, for example, journalists uncovered how a group of private 
investment firms acquired 49 nursing homes, including a facility in 
Florida where managers slashed the number of registered nurses by half 
and cut supply and activity budgets. Residents, meanwhile, suffered 
from preventable infections and injuries.\4\ Last year, news reports 
similarly detailed how a for-profit nursing home employed drastic cost 
cutting measures, ``exposed its roughly 25,000 patients to increasing 
health risk,' and ultimately filed for bankruptcy--all after a private 
equity firm acquired the company.\5\
---------------------------------------------------------------------------
    \2\ National Center for Health Statistics, ``Long-term Care 
Providers and Services Users in the United States, 2015-2016,'' 
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
    \3\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html; Reveal, ``The rats sensed she was 
going to pass away,'' Jennifer Gollan, September 18, 2019, https://
www.revealnews.org/article/elderly-often-face-neglect-in-california-
care-homes-that-exploit-workers/.
    \4\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
    \5\ Washington Post, ``Overdoses, bedsores, broken bones: What 
happened when a private-equity firm sought to care for society's most 
vulnerable,'' Peter Whoriskey and Dan Keating, November 25, 2018, 
https://www.washingtonpost.com/business/economy/opioid-overdoses-
bedsores-and-broken-bones-what-happened-when-a-private-equity-firm-
sought-profits-in-caring-for-societys-most
-vulnerable/2018/11/25/09089a4a-ed14-11e8-baac-2a674e91502b_story.html.

This is particularly concerning given the fact that two-thirds of 
nursing home residents rely on government-sponsored health insurance 
coverage, meaning both not-for-profit and for-profit nursing homes 
benefit from government funding.\6\ Medicaid is the primary payer \7\ 
for nursing home care, with Medicare and Medicaid combined covering 
approximately 75 percent of nursing home residents.\8\ In 2015, 
taxpayers sent more than $55 billion to the nursing home industry to 
cover the costs of long-term care. These reports and corresponding 
research raise serious questions about the role of private equity firms 
in the nursing home care industry, and the extent to which these firms' 
emphasis on profits and short-term return is responsible for declines 
in quality of care. They also raise concerns over the stewardship of 
taxpayer dollars, when--in many cases--these facilities continue to 
receive Medicare and Medicaid funding despite their decline in quality.
---------------------------------------------------------------------------
    \6\ Kaiser Family Foundation, ``Distribution of Certified Nursing 
Facility Residents by Primary Payer Source,'' accessed on Nov. 14, 
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
    \7\ Kaiser Family Foundation, ``Medicaid's Role in Nursing Home 
Care,'' June 20, 2017, https://www.kff.org/infographic/medicaids-role-
in-nursing-home-care/.
    \8\ Kaiser Family Foundation, ``Distribution of Certified Nursing 
Facility Residents by Primary Payer Source,'' accessed on Nov. 14, 
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

The majority of nursing facilities--almost 70%--are for-profit, and 
over half are chain-affiliated.\9\ The overwhelming majority of 
research conducted over the last 2 decades shows that for-profit and 
chain affiliated \10\ companies provide a lower quality of care and 
experience more serious health and safety deficiencies when compared to 
non-profit facilities.\11\
---------------------------------------------------------------------------
    \9\ National Center for Health Statistics, ``Long-term Care 
Providers and Services Users in the United States, 2015-2016,'' 
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
    \10\ Facilities owned or leased by ``an organization that owns two 
or more long-term care facilities.''
    \11\ International Journal of Health Services, ``Ownership, 
Financing, and Management Strategies of the 10 largest for-profit 
nursing home chains in the United States,'' Charlene Harrington et al., 
2011; Medical Care Research and Review, ``Nursing home profit status 
and quality of care: Is there any evidence of an association?'', 
Michael P. Hillmer et al., April 2005, https://www.ncbi.nlm.nih.gov/
pubmed/15750174.

Additionally, for-profit facilities receive the lowest scores in the 
Centers for Medicare and Medicaid Services' (CMS) nursing home rating 
system that takes into account, state health inspections, staffing 
ratios and quality measures.\12\
---------------------------------------------------------------------------
    \12\ Kaiser Family Foundation, ``Reading the Stars: Nursing Home 
Quality Star Ratings, Nationally and by State,'' May 2015, http://
files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-
quality-star-ratings-nationally-and-by-state.

Private equity investment appears to exacerbate the problems faced at 
chain-
affiliated for-profit nursing homes. Studies show that private equity-
owned facilities generally ``deliver poorer quality of care'' than 
other chain-affiliated for-profit facilities; are likely to try to 
reduce cost by ``substituting expensive but skilled RNs with cheaper 
and less skilled nurses;'' and ``report significantly higher number of 
deficiencies'' that climb with more years of private equity ownership. 
As a result, private equity-owned nursing homes have 21% higher 
deficiencies, 25% lower nursing staff skill mix, and ``worse results on 
pressure sore prevention . . . and [higher] pressure ulcer [] risk 
prevalence.''\13\ That was reportedly the case at HCR ManorCare--the 
second largest for-profit nursing home chain in the United States. In 
the years following its acquisition by your firm, ``the number of 
citations increased for, among other things, neither preventing nor 
treating bed sores; medication errors; not providing proper care for 
people who need special services such as injections, colostomies and 
prostheses; and not assisting patients with eating and personal 
hygiene.''\14\
---------------------------------------------------------------------------
    \13\ Journal of Health Care Finance, ``Private Equity Ownership of 
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
    \14\ Washington Post, ``Overdoses, bedsores, broken bones: What 
happened when a private-
equity firm sought to care for society's most vulnerable,'' Peter 
Whoriskey and Dan Keating, November 25, 2018, https://
www.washingtonpost.com/business/economy/opioid-overdoses-bedsores-and-
broken-bones-what-happened-when-a-private-equity-firm-sought-profits-
in-caring-for-societys-most-vulnerable/2018/11/25/09089a4a-ed14-11e8-
baac-2a674e91502b_story.html.

Moreover, while the quality of service declines, the complicated 
ownership and operating structure of these investments ``limit legal 
remedies available to aggrieved residents.''\15\ For example, after a 
resident died at the private-equity-owned Habana Health Care Center (as 
a result of ``a wound [that] should have been detected much earlier''), 
a family member tried to sue the owners of the facility, only to 
discover that the facility's complicated ownership structure ``meant 
that even if she prevailed in court, the investors' wallets would 
likely be out of reach.''\16\ Shifting funds to other affiliated 
entities, or to the private equity firm itself, to immunize itself from 
liability for judgments against a target company is a widespread 
practice in the private equity industry.
---------------------------------------------------------------------------
    \15\ Journal of Health Care Finance, ``Private Equity Ownership of 
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
    \16\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2007, https://www.nytimes.com/
2007/09/23/business/23nursing.html.

Private equity investment in this sector has increased over the last 
few decades. The Government Accountability Office found that over the 
span of 10 years ending in 2008, private investment firms acquired 
approximately 1,900 unique nursing homes.\17\ Today, private equity 
firms own or operate several large for-profit chains that control 
hundreds of facilities and provide nursing home care among other long-
term care services.\18\ Carlyle reportedly owns or has had investments 
in companies providing nursing home care. In order to help us 
understand your firm' s role in the nursing home sector, we ask that 
you provide answers to the following questions no later than November 
29, 2019.
---------------------------------------------------------------------------
    \17\ Government Accountability Office, ``Nursing Homes: Complexity 
of Private Investment Purchases Demonstrates Need for CMS to Improve 
the Usability and Completeness of Ownership Data,'' September 2010, 
https://www.gao.gov/assets/320/310562.pdf.
    \18\ IQVIA, ``U.S. Elder Care Market Summary,'' September 2019, 
https://www.skainfo.com/reports/u.s.-elder-care-market-summary.

      1.  Please provide the disclosure documents and information 
enumerated in Sections 501 and 503 of the Stop Wall Street Looting 
Act.\19\
---------------------------------------------------------------------------
    \19\ Stop Wall Street Looting Act, S. 2155, https://
www.congress.gov/bill/116th-congress/senate-bill/2155.

      2.  Which nursing home or other long-term care service companies, 
including all affiliates or related entities, does Carlyle have a stake 
in or own? Please provide the name of and a brief description of the 
services each company provides--including the number of facilities that 
---------------------------------------------------------------------------
it owns or operates.

        a.  Which nursing home or other long-term care companies, 
including all affiliates or related entities, has Carlyle had a stake 
in or owned in the past 20 years? Please provide the name of and a 
brief description of the services each company provides or provided--
including the number of nursing home and other long-term care 
facilities that it owned or operated.

        b.  For each nursing home or other long-term care service 
company Carlyle had a stake in or owned in the past 20 years, including 
all affiliates or related entities, please provide the following 
information for each year that the firm have had a stake in or owned 
this company and the 5 years preceding the firm's investment.

            i.  The name of the company
            ii.  Total number of facilities, by type of facility
           iii.  Ownership stake
           iv.  Total revenue, and the total revenue from Medicare, and 
from Medicaid
           v.  Total transaction, advisory, or other fees collected 
after the acquisition of the company
           vi.  Net income
          vii.  Total number of employees for each facility
          viii.  Total number of patients for each facility, and the 
total number whose care is paid for by Medicare, and by Medicaid
           ix.  Other private-equity firms that own a stake in the 
company


      3.  Private-equity firms reportedly employ sale-leaseback 
arrangements in order to quickly recover investments. For each company 
listed in questions 2(a) and 2(b), please list the number of nursing 
home or other long-term care facilities for which you acquired real 
estate assets, and whether a sale-leaseback agreement has been executed 
for any of those companies or facilities.

      4.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Carlyle has an 
ownership stake or has had an ownership stake in the last 20 years 
received Section 232 Department of Housing and Urban Development (HUD)-
insured mortgages? If so, please provide the name of each facility and 
the total value of each loan insured by HUD.

      5.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Carlyle has an 
ownership stake or has had an ownership stake in the last 20 years, 
been placed in receivership? Please provide the name of each facility.

      6.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Carlyle has an 
ownership stake or has had an ownership stake in the last 20 years, 
been found to have violated any federal or state laws or regulations? 
If so, please provide a complete list, including the date and 
description, of all such violations. Please also include a list of all 
deficiencies identified in state or federal surveys of the facilities 
owned by the company for each year.

      7.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Carlyle has an 
ownership stake or has had an ownership stake in the last 20 years, 
reached a settlement with any federal or state law enforcement entity 
related to a potential violation of any federal or state laws or 
regulations or deficiencies in providing care? If so, please provide a 
complete list, including the date and description, of all such 
settlements.

      8.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Carlyle has an 
ownership stake or has had an ownership stake in the past 20 years, 
reached a settlement with any individual who was provided services by 
the company related to a potential violation of any federal or state 
laws or regulations or deficiencies in providing care? If so, please 
provide a complete list, including the date and description, of all 
such settlements.

Thank you for your attention to this matter.

            Sincerely,

Elizabeth Warren                    Mark Pocan
United States Senator               Member of Congress

Sherrod Brown
United States Senator

                                 ______
                                 

                     Congress of the United States

                          Washington, DC 20510

                           November 15, 2019

Arnold Whitman
Chairman
Formation Capital
3500 Lenox Road, Suite 510
Atlanta, Georgia 30326

Brian Beckwith
Formation Capital
3500 Lenox Road, Suite 510
Atlanta, Georgia 30326

Dear Messrs. Whitman and Beckwith:

We are writing to request information regarding Formation Capital's 
(Formation) investment in companies providing nursing home care and 
other long-term care services and to request information about your 
firm' s structure and finances as it relates to these companies.

Private equity funds often operate under a model where they purchase 
controlling interests in companies for a short time, load them up with 
debt, strip them of their assets, extract exorbitant fees, and sell 
them at a profit--implementing drastic cost-cutting measures at the 
expense of consumers, workers, communities, and taxpayers. For that 
reason, we have concerns about the rapid spread and effect of private 
equity investment in many sectors of the economy, especially industries 
that affect vulnerable populations and rely primarily on taxpayer-
funded programs such as Medicare and Medicaid, like the nursing home 
industry. We are particularly concerned about your firm's investment in 
large for-profit nursing home chains, which research has shown often 
provide worse care than not-for-profit facilities.\1\ In light of these 
concerns, we request information about your firm, the portfolio 
companies in which it has invested, and the performance of those 
investments.
---------------------------------------------------------------------------
    \1\ International Journal of Health Services, ``Ownership, 
Financing, and Management Strategies of the 10 largest for-profit 
nursing home chains in the United States,'' Charlene Harrington et al., 
2011, https://www.ncbi.nlm.nih.gov/pubmed/22053531; Kaiser Family 
Foundation, ``Reading the Stars: Nursing Home Quality Star Ratings, 
Nationally and by State,'' May 2015, http://files.kff.org/attachment/
issue-brief-reading-the-stars-nursing-home-quality-star-ratings-
nationally-and-by-state.

Nursing homes provide a wide range of important medical and personal 
care services to a growing and vulnerable elderly population, with 1.3 
million residents in the United States currently receiving care in more 
than 15,000 facilities.\2\ For decades, reports and data have 
highlighted the shocking living conditions found in many nursing home 
and other long-term care facilities across the country.\3\ Twelve years 
ago, for example, journalists uncovered how a group of private 
investment firms acquired 49 nursing homes, including a facility in 
Florida where managers slashed the number of registered nurses by half 
and cut supply and activity budgets. Residents, meanwhile, suffered 
from preventable infections and injuries.\4\ Last year, news reports 
similarly detailed how a for-profit nursing home employed drastic cost 
cutting measures, ``exposed its roughly 25,000 patients to increasing 
health risk,'' and ultimately filed for bankruptcy--all after a private 
equity firm acquired the company.\5\
---------------------------------------------------------------------------
    \2\ National Center for Health Statistics, ``Long-term Care 
Providers and Services Users in the United States, 2015-2016,'' 
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
    \3\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html; Reveal, ``The rats sensed she was 
going to pass away,'' Jennifer Gollan, September 18, 2019, https://
www.revealnews.org/article/elderly-often-face-neglect-in-california-
care-homes-that-exploit-workers/.
    \4\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
    \5\ Washington Post, ``Overdoses, bedsores, broken bones: What 
happened when a private-equity firm sought to care for society's most 
vulnerable,'' Peter Whoriskey and Dan Keating, November 25, 2018, 
https://www.washingtonpost.com/business/economy/opioid-overdoses-
bedsores-and-broken-bones-what-happened-when-a-private-equity-firm-
sought-profits-in-caring-for-societys-most
-vulnerable/2018/11/25/09089a4a-ed14-11e8-baac-2a674e91502b_story.html.

This is particularly concerning given the fact that two-thirds of 
nursing home residents rely on government-sponsored health insurance 
coverage, meaning both not-for-profit and for-profit nursing homes 
benefit from government funding.\6\ Medicaid is the primary payer \7\ 
for nursing home care, with Medicare and Medicaid combined covering 
approximately 75 percent of nursing home residents.\8\ In 2015, 
taxpayers sent more than $55 billion to the nursing home industry to 
cover the costs of long-term care. These reports and corresponding 
research raise serious questions about the role of private equity firms 
in the nursing home care industry, and the extent to which these firms' 
emphasis on profits and short-term return is responsible for declines 
in quality of care. They also raise concerns over the stewardship of 
taxpayer dollars, when--in many cases--these facilities continue to 
receive Medicare and Medicaid funding despite their decline in quality.
---------------------------------------------------------------------------
    \6\ Kaiser Family Foundation, ``Distribution of Certified Nursing 
Facility Residents by Primary Payer Source,'' accessed on Nov. 14, 
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22.%22sort%22:%22asc%22%7D.
    \7\ Kaiser Family Foundation, ``Medicaid's Role in Nursing Home 
Care,'' June 20,2017, https://www.kff.org/infographic/medicaids-role-
in-nursing-home-care/.
    \8\ Kaiser Family Foundation, ``Distribution of Certified Nursing 
Facility Residents by Primary Payer Source,'' accessed on Nov. 14, 
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colld%22:%22Location%22,%22sort%22:%22asc%22%7D.

The majority of nursing facilities--almost 70%--are for-profit, and 
over half are chain-affiliated.\9\ The overwhelming majority of 
research conducted over the last 2 decades shows that for-profit and 
chain affiliated \10\ companies provide a lower quality of care and 
experience more serious health and safety deficiencies when compared to 
non-profit facilities.\11\
---------------------------------------------------------------------------
    \9\ National Center for Health Statistics, ``Long-term Care 
Providers and Services Users in the United States, 2015-2016,'' 
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
    \10\ Facilities owned or leased by ``an organization that owns two 
or more long-term care facilities.''
    \11\ International Journal of Health Services, ``Ownership, 
Financing, and Management Strategies of the ten largest for-profit 
nursing home chains in the United States,'' Charlene Harrington et al., 
2011; Medical Care Research and Review, ``Nursing home profit status 
and quality of care: Is there any evidence of an association?'', 
Michael P. Hillmer et al., April 2005, https://www.ncbi.nlm.nih.gov/
pubmed/15750174.

Additionally, for-profit facilities receive the lowest scores in the 
Centers for Medicare and Medicaid Services' (CMS) nursing home rating 
system that takes into account, state health inspections, staffing 
ratios and quality measures. \12\
---------------------------------------------------------------------------
    \12\ Kaiser Family Foundation, ``Reading the Stars: Nursing Home 
Quality Star Ratings, Nationally and by State,'' May 2015, http://
files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-
quality-star-ratings-nationallyand-by-state.

Private equity investment appears to exacerbate the problems faced at 
chain-
affiliated for-profit nursing homes. Studies show that private equity-
owned facilities generally ``deliver poorer quality of care'' than 
other chain-affiliated for-profit facilities; are likely to try to 
reduce cost by ``substituting expensive but skilled RNs with cheaper 
and less skilled nurses;'' and ``report significantly higher number of 
deficiencies'' that climb with more years of private equity ownership. 
As a result, private equity-owned nursing homes have 21% higher 
deficiencies, 25% lower nursing staff skill mix, and ``worse results on 
pressure sore prevention . . . and [higher] pressure ulcer [] risk 
prevalence.''\13\ That was reportedly the case at HCR ManorCare--the 
second largest for-profit nursing home chain in the United States. In 
the years following its acquisition by a private equity firm, ``the 
number of citations increased for, among other things, neither 
preventing nor treating bed sores; medication errors; not providing 
proper care for people who need special services such as injections, 
colostomies and prostheses; and not assisting patients with eating and 
personal hygiene.''\14\
---------------------------------------------------------------------------
    \13\ Journal of Health Care Finance, ``Private Equity Ownership of 
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
    \14\ Washington Post, ``Overdoses, bedsores, broken bones: What 
happened when a private-
equity firm sought to care for society's most vulnerable,'' Peter 
Whoriskey and Dan Keating, November 25, 2018, https://
www.washingtonpost.com/business/economy/opioid-overdoses-bedsores-and-
broken-bones-what-happened-when-a-private-equity-firm-sought-profits-
in-caring-for-societys-most-vulnerable/2018/11/25/09089a4a-ed14-11e8-
baac-2a674e91502b_story.html.

Moreover, while the quality of service declines, the complicated 
ownership and operating structure of these investments ``limit legal 
remedies available to aggrieved residents.''\15\ For example, after a 
resident died at the private-equity-owned Habana Health Care Center (as 
a result of ``a wound [that] should have been detected much earlier''), 
a family member tried to sue the owners of the facility, only to 
discover that the facility's complicated ownership structure ``meant 
that even if she prevailed in court, the investors' wallets would 
likely be out of reach.''\16\ Shifting funds to other affiliated 
entities, or to the private equity firm itself, to immunize itself from 
liability for judgments against a target company is a widespread 
practice in the private equity industry.
---------------------------------------------------------------------------
    \15\ Journal of Health Care Finance, ``Private Equity Ownership of 
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
    \16\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2007, https://www.nytimes.com/
2007/09/23/business/23nursing.html.

Private equity investment in this sector has increased over the last 
few decades. The Government Accountability Office found that over the 
span of 10 years ending in 2008, private investment firms acquired 
approximately 1,900 unique nursing homes.\17\ Today, private equity 
firms own or operate several large for-profit chains that control 
hundreds of facilities and provide nursing home care among other long-
term care services.\18\ Formation reportedly owns or has had 
investments in companies providing nursing home care. In order to help 
us understand your firm's role in the nursing home sector, we ask that 
you provide answers to the following questions no later than November 
29, 2019.
---------------------------------------------------------------------------
    \17\ Government Accountability Office, ``Nursing Homes: Complexity 
of Private Investment Purchases Demonstrates Need for CMS to Improve 
the Usability and Completeness of Ownership Data,'' September 2010, 
https://www.gao.gov/assets/320/310562.pdf.
    \18\ IQVIA, ``U.S. Elder Care Market Summary,'' September 2019, 
https://www.skainfo.com/reports/u.s.-elder-care-market-summary.

      1.  Please provide the disclosure documents and information 
enumerated in Sections 501 and 503 of the Stop Wall Street Looting 
Act.\19\
---------------------------------------------------------------------------
    \19\ Stop Wall Street Looting Act, S. 2155, https://
www.congress.gov/bill/116th-congress/senate-bill/2155.

      2.  Which nursing home or other long-term care service companies, 
including all affiliates or related entities, does Formation have a 
stake in or own? Please provide the name of and a brief description of 
the services each company provides--including the number of facilities 
---------------------------------------------------------------------------
that it owns or operates.

        a.  Which nursing home or other long-term care companies, 
including all affiliates or related entities, has Formation had a stake 
in or owned in the past 20 years? Please provide the name of and a 
brief description of the services each company provides or provided-
including the number of nursing home and other long-term care 
facilities that it owned or operated.

        b.  For each nursing home or other long-term care service 
company Formation had a stake in or owned in the past 20 years, 
including all affiliates or related entities, please provide the 
following information for each year that the firm have had a stake in 
or owned this company and the 5 years preceding the firm's investment.

            i.  The name of the company
            ii.  Total number of facilities, by type of facility
           iii.  Ownership stake
           iv.  Total revenue, and the total revenue from Medicare, and 
from Medicaid
           v.  Total transaction, advisory, or other fees collected 
after the acquisition of the company
           vi.  Net income
          vii.  Total number of employees for each facility
          viii.  Total number of patients for each facility, and the 
total number whose care is paid for by Medicare, and by Medicaid
           ix.  Other private-equity firms that own a stake in the 
company pany

      3.  Private-equity firms reportedly employ sale-leaseback 
arrangements in order to quickly recover investments. For each company 
listed in questions 2(a) and 2(b), please list the number of nursing 
home or other long-term care facilities for which you acquired real 
estate assets, and whether a sale-leaseback agreement has been executed 
for any of those companies or facilities.

      4.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Formation has an 
ownership stake or has had an ownership stake in the last 20 years 
received Section 232 Department of Housing and Urban Development (HUD)-
insured mortgages? If so, please provide the name of each facility and 
the total value of each loan insured by HUD.

      5.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Formation has an 
ownership stake or has had an ownership stake in the last 20 years, 
been placed in receivership? Please provide the name of each facility.

      6.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Formation has an 
ownership stake or has had an ownership stake in the last 20 years, 
been found to have violated any federal or state laws or regulations? 
If so, please provide a complete list, including the date and 
description, of all such violations. Please also include a list of all 
deficiencies identified in state or federal surveys of the facilities 
owned by the company for each year.

      7.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Formation has an 
ownership stake or has had an ownership stake in the last 20 years, 
reached a settlement with any federal or state law enforcement entity 
related to a potential violation of any federal or state laws or 
regulations or deficiencies in providing care? If so, please provide a 
complete list, including the date and description, of all such 
settlements.

      8.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Formation has an 
ownership stake or has had an ownership stake in the past 20 years, 
reached a settlement with any individual who was provided services by 
the company related to a potential violation of any federal or state 
laws or regulations or deficiencies in providing care? If so, please 
provide a complete list, including the date and description, of all 
such settlements.

Thank you for your attention to this matter.

            Sincerely,

Elizabeth Warren                    Mark Pocan
United States Senator               United States Congress

Sherrod Brown
United States Senator

                                 ______
                                 

                     Congress of the United States

                          Washington, DC 20510

                           November 15, 2019

Ronald E. Silva
President and Chief Executive Officer
Fillmore Capital Partners
Four Embarcadero Center, Suite 710
San Francisco, CA 94111

Dear Mr. Silva:

We are writing to request information regarding Fillmore Capital 
Partners' (Fillmore) investment in companies providing nursing home 
care and other long-term care services and to request information about 
your firm's structure and finances as it relates to these companies.

Private equity funds often operate under a model where they purchase 
controlling interests in companies for a short time, load them up with 
debt, strip them of their assets, extract exorbitant fees, and sell 
them at a profit--implementing drastic cost-cutting measures at the 
expense of consumers, workers, communities, and taxpayers. For that 
reason, we have concerns about the rapid spread and effect of private 
equity investment in many sectors of the economy, especially industries 
that affect vulnerable populations and rely primarily on taxpayer-
funded programs such as Medicare and Medicaid, like the nursing home 
industry. We are particularly concerned about your firm's investment in 
large for-profit nursing home chains, which research has shown often 
provide worse care than not-for-profit facilities.\1\ In light of these 
concerns, we request information about your firm, the portfolio 
companies in which it has invested, and the performance of those 
investments.
---------------------------------------------------------------------------
    \1\ International Journal of Health Services, ``Ownership, 
Financing, and Management Strategies of the 10 largest for-profit 
nursing home chains in the United States,'' Charlene Harrington et al., 
2011, https://www .ncbi.nlm.nih.gov/pubmed/22053531; Kaiser Family 
Foundation, ``Reading the Stars: Nursing Home Quality Star Ratings, 
Nationally and by State,'' May 2015, http://files.kff.org/attachment/
issue-brief-reading-the-stars-nursing-home-quality-star-ratings-
nationally-and-by-state.

Nursing homes provide a wide range of important medical and personal 
care services to a growing and vulnerable elderly population, with 1.3 
million residents in the United States currently receiving care in more 
than 15,000 facilities.\2\ For decades, reports and data have 
highlighted the shocking living conditions found in many nursing home 
and other long-term care facilities across the country.\3\ Twelve years 
ago, for example, journalists uncovered how a group of private 
investment firms acquired 49 nursing homes, including a facility in 
Florida where managers slashed the number of registered nurses by half 
and cut supply and activity budgets. Residents, meanwhile, suffered 
from preventable infections and injuries.\4\ Last year, news reports 
similarly detailed how a for-profit nursing home employed drastic cost 
cutting measures, ``exposed its roughly 25,000 patients to increasing 
health risk,'' and ultimately filed for bankruptcy--all after a private 
equity firm acquired the company.\5\
---------------------------------------------------------------------------
    \2\ National Center for Health Statistics, ``Long-term Care 
Providers and Services Users in the United States, 2015-2016,'' 
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
    \3\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html; Reveal, ``The rats sensed she was 
going to pass away,'' Jennifer Gollan, September 18, 2019, https://
www.revealnews.org/article/elderly-often-face-neglect-in-california-
care-homes-that-exploit-workers/.
    \4\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
    \5\ Washington Post, ``Overdoses, bedsores, broken bones: What 
happened when a private-equity firm sought to care for society's most 
vulnerable,'' Peter Whoriskey and Dan Keating, November 25, 2018, 
https://www.washingtonpost.com/business/economy/opioid-overdoses-
bedsores-and-broken-bones-what-happened-when-a-private-equity-firm-
sought-profits-in-caring-for-societys-most-vulnerable/2018/11/25/
09089a4a-ed14-11e8-baac-2a674e91502b_story.html.

This is particularly concerning given the fact that two-thirds of 
nursing home residents rely on govenunent-sponsored health insurance 
coverage, meaning both not-for-profit and for-profit nursing homes 
benefit from government funding.\6\ Medicaid is the primary payer \7\ 
for nursing home care, with Medicare and Medicaid combined covering 
approximately 75 percent of nursing home residents.\8\ In 2015, 
taxpayers sent more than $55 billion to the nursing home industry to 
cover the costs of long-term care. These reports and corresponding 
research raise serious questions about the role of private equity firms 
in the nursing home care industry, and the extent to which these firms' 
emphasis on profits and short-term return is responsible for declines 
in quality of care. They also raise concerns over the stewardship of 
taxpayer dollars, when--in many cases--these facilities continue to 
receive Medicare and Medicaid funding despite their decline in quality.
---------------------------------------------------------------------------
    \6\ Kaiser Family Foundation. ``Distribution of Certified Nursing 
Facility Residents by Primary Payer Source,'' accessed on Nov. 14, 
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22.%22sort%22:%22asc%22%7D.
    \7\ Kaiser Family Foundation, ``Medicaid's Role in Nursing Home 
Care,'' June 20, 2017, https://www.kff.org/infographic/medicaids-role-
in-nursing-home-care/.
    \8\ Kaiser Family Foundation, ``Distribution of Certified Nursing 
Facility Residents by Primary Payer Source,'' accessed on Nov. 14, 
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.

The majority of nursing facilities--almost 70%--are for-profit, and 
over half are chain-affiliated.\9\ The overwhelming majority of 
research conducted over the last 2 decades shows that for-profit and 
chain affiliated \10\ companies provide a lower quality of care and 
experience more serious health and safety deficiencies when compared to 
non-profit facilities.\11\ Additionally, for-profit facilities receive 
the lowest scores in the Centers for Medicare and Medicaid Services' 
(CMS) nursing home rating system that takes into account, state health 
inspections, staffing ratios and quality measures.\12\
---------------------------------------------------------------------------
    \9\ National Center for Health Statistics, ``Long-term Care 
Providers and Services Users in the United States, 2015-2016,'' 
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
    \10\ Facilities owned or leased by ``an organization that owns two 
or more long-term care facilities.''
    \11\ International Journal of Health Services, ``Ownership, 
Financing, and Management Strategies of the 10 largest for-profit 
nursing home chains in the United States,'' Charlene Harrington et al., 
2011; Medical Care Research and Review, ``Nursing home profit status 
and quality of care: Is there any evidence of an association?'', 
Michael P. Hillmer et al., Apri1 2005, https://www.ncbi.nlm.nih.gov/
pubmed/15750174.
    \12\ Kaiser Family Foundation, ``Reading the Stars: Nursing Home 
Quality Star Ratings, Nationally and by State,'' May 2015, http://
files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-
quality-star-ratings-nationally-and-by-state.

Private equity investment appears to exacerbate the problems faced at 
chain-
affiliated for-profit nursing homes. Studies show that private equity-
owned facilities generally ``deliver poorer quality of care'' than 
other chain-affiliated for-profit facilities; are likely to try to 
reduce cost by ``substituting expensive but skilled RNs with cheaper 
and less skilled nurses;'' and ``report significantly higher number of 
deficiencies'' that climb with more years of private equity ownership. 
As a result, private equity-owned nursing homes have 21% higher 
deficiencies, 25% lower nursing staff skill mix, and ``worse results on 
pressure sore prevention . . . and [higher] pressure ulcer [] risk 
prevalence.''\13\ That was reportedly the case at HCR ManorCare--the 
second largest for-profit nursing home chain in the United States. In 
the years following its acquisition by a private equity firm, ``the 
number of citations increased for, among other things, neither 
preventing nor treating bed sores; medication errors; not providing 
proper care for people who need special services such as injections, 
colostomies and prostheses; and not assisting patients with eating and 
personal hygiene.''\14\
---------------------------------------------------------------------------
    \13\ Journal of Health Care Finance, ``Private Equity Ownership of 
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
    \14\ Washington Post, ``Overdoses, bedsores, broken bones: What 
happened when a private-
equity firm sought to care for society's most vulnerable,'' Peter 
Whoriskey and Dan Keating, November 25, 2018, https://
www.washingtonpost.com/business/economy/opioid-overdoses-bedsores-and-
broken-bones-what-happened-when-a-private-equity-firm-sought-profits-
in-caring-for-societys-most-vulnerable/2018/11/25/09089a4a-ed14-11e8-
baac-2a674e91502b_story.html.

Moreover, while the quality of service declines, the complicated 
ownership and operating structure of these investments ``limit legal 
remedies available to aggrieved residents.''\15\ For example, after a 
resident died at the private-equity-owned Habana Health Care Center (as 
a result of ``a wound [that] should have been detected much earlier''), 
a family member tried to sue the owners of the facility, only to 
discover that the facility's complicated ownership structure ``meant 
that even if she prevailed in court, the investors' wallets would 
likely be out of reach.''\16\ Shifting funds to other affiliated 
entities, or to the private equity firm itself, to immunize itself from 
liability for judgments against a target company is a widespread 
practice in the private equity industry.
---------------------------------------------------------------------------
    \15\ Journal of Health Care Finance, ``Private Equity Ownership of 
Nursing Homes: Implications for Quality,'' Rohit Pradban et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
    \16\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2007, https://www.nytimes.com/
2007/09/23/business/23nursing.html.

Private equity investment in this sector has increased over the last 
few decades. The Government Accountability Office found that over the 
span of 10 years ending in 2008, private investment firms acquired 
approximately 1,900 unique nursing homes.\17\ Today, private equity 
firms own or operate several large for-profit chains that control 
hundreds of facilities and provide nursing home care among other long-
term care services.\18\ Fillmore reportedly owns or has had investments 
in companies providing nursing home care. In order to help us 
understand your firm's role in the nursing home sector, we ask that you 
provide answers to the following questions no later than November 29, 
2019.
---------------------------------------------------------------------------
    \17\ Government Accountability Office, ``Nursing Homes: Complexity 
of Private Investment Purchases Demonstrates Need for CMS to Improve 
the Usability and Completeness of Ownership Data,'' September 2010, 
https://www.gao.gov/assets/320/310562.pdf.
    \18\ IQVIA, ``U.S. Elder Care Market Summary,'' September 2019, 
https://www.skainfo.com/reports/u.s.-elder-care-market-summary.

      1.  Please provide the disclosure documents and information 
enumerated in Sections 501 and 503 of the Stop Wall Street Looting 
Act.\19\
---------------------------------------------------------------------------
    \19\ Stop Wall Street Looting Act, S. 2155, https://
www.congress.gov/bill/116th-congress/senate-bill/2155.

      2.  Which nursing home .or other long-term care service 
companies, including all affiliates or related entities, does Fillmore 
have a stake in or own? Please provide the name of and a brief 
description of the services each company provides--including the number 
---------------------------------------------------------------------------
of facilities that it owns or operates.

        a.  Which nursing home or other long-term care companies, 
including all affiliates or related entities, has Fillmore had a stake 
in or owned in the past 20 years? Please provide the name of and a 
brief description of the services each company provides or provided--
including the number of nursing home and other long-term care 
facilities that it owned or operated.

        b.  For each nursing home or other long-term care service 
company Fillmore had a stake in or owned in the past 20 years, 
including all affiliates or related entities, please provide the 
following information for each year that the firm have had a stake in 
or owned this company and the 5 years preceding the firm's investment.

            i.  The name of the company
            ii.  Total number of facilities, by type of facility
           iii.  Ownership stake
           iv.  Total revenue, and the total revenue from Medicare, and 
from Medicaid
           v.  Total transaction, advisory, or other fees collected 
after the acquisition of the company
           vi.  Net income
          vii.  Total number of employees for each facility
          viii.  Total number of patients for each facility, and the 
total number whose care is paid for by Medicare, and by Medicaid
           ix.  Other private-equity firms that own a stake in the 
company

      3.  Private-equity firms reportedly employ sale-leaseback 
arrangements in order to quickly recover investments. For each company 
listed in questions 2(a) and 2(b), please list the number of nursing 
home or other long-term care facilities for which you acquired real 
estate assets, and whether a sale-leaseback agreement has been executed 
for any of those companies or facilities.

      4.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Fillmore has an 
ownership stake or has had an ownership stake in the last 20 years 
received Section 232 Department and Urban Development (HUD)-insured 
mortgages? If so, please provide the name of each facility and the 
total value of each loan insured by HUD.

      5.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Fillmore has an 
ownership stake or has had an ownership stake in the last 20 years, 
been placed in receivership? Please provide the name of each facility.

      6.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Fillmore has an 
ownership stake or has had an ownership stake in the last 20 years, 
been found to have violated any federal or state laws or regulations? 
If so, please provide a complete list, including the date and 
description, of all such violations. Please also include a list of all 
deficiencies identified in state or federal surveys of the facilities 
owned by the company for each year.

      7.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Fillmore has an 
ownership stake or has had an ownership stake in the last 20 years, 
reached a settlement with any federal or state law enforcement entity 
related to a potential violation of any federal or state laws or 
regulations or deficiencies in providing care? If so, please provide a 
complete list, including the date and description, of all such 
settlements.

      8.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Fillmore has an 
ownership stake or has had an ownership stake in the past 20 years, 
reached a settlement with any individual who was provided services by 
the company related to a potential violation of any federal or state 
laws or regulations or deficiencies in providing care? If so, please 
provide a complete list, including the date and description, of all 
such settlements.

Thank you for your attention to this matter.

            Sincerely,

Elizabeth Warren                    Mark Pocan
United States Senator               United States Congress

Sherrod Brown
United States Senator

                                 ______
                                 

                     Congress of the United States

                          Washington, DC 20510

                           November 15, 2019

Charles R. Kaye
Co-Chief Executive Officer
Warburg Pincus LLC
450 Lexington Ave.
New York, NY 10017

Joseph P. Landy
Co-Chief Executive Officer
Warburg Pincus LLC
450 Lexington Ave.
New York, NY 10017

Dear Messrs. Kaye and Landy:

We are writing to request information regarding Warburg Pincus LLC's 
(Warburg Pincus) investment in companies providing nursing home care 
and other long-term care services and to request information about your 
firm's structure and finances as it relates to these companies.

Private equity funds often operate under a model where they purchase 
controlling interests in companies for a short time, load them up with 
debt, strip them of their assets, extract exorbitant fees, and sell 
them at a profit -implementing drastic cost-cutting measures at the 
expense of consumers, workers, communities, and taxpayers. For that 
reason, we have concerns about the rapid spread and effect of private 
equity investment in many sectors of the economy, especially industries 
that affect vulnerable populations and rely primarily on taxpayer-
funded programs such as Medicare and Medicaid, like the nursing home 
industry. We are particularly concerned about your firm's investment in 
large for-profit nursing home chains, which research has shown often 
provide worse care than not-for-profit facilities.\1\ In light of these 
concerns, we request information about your firm, the portfolio 
companies in which it has invested, and the performance of those 
investments.
---------------------------------------------------------------------------
    \1\ International Journal of Health Services, ``Ownership, 
Financing, and Management Strategies of the 10 largest for-profit 
nursing home chains in the United States,'' Charlene Harrington et al., 
2011, https://www.ncbi.nlm.nih.gov/pubmed/22053531; Kaiser Family 
Foundation, ``Reading the Stars: Nursing Home Quality Star Ratings, 
Nationally and by State,'' May 2015, http://files.kff.org/attachment/
issue-brief-reading-the-stars-nursing-home-quality-star-ratings-
nationally-and-by-state.

Nursing homes provide a wide range of important medical and personal 
care services to a growing and vulnerable elderly population, with 1.3 
million residents in the United States currently receiving care in more 
than 15,000 facilities.\2\ For decades, reports and data have 
highlighted the shocking living conditions found in many nursing home 
and other long-term care facilities across the country.\3\ Twelve years 
ago, for example, journalists uncovered how a group of private 
investment firms acquired 49 nursing homes, including a facility in 
Florida where managers slashed the number of registered nurses by half 
and cut supply and activity budgets. Residents, meanwhile, suffered 
from preventable infections and injuries.\4\ Last year, news reports 
similarly detailed how a for-profit nursing home employed drastic cost 
cutting measures, ``exposed its roughly 25,000 patients to increasing 
health risk,'' and ultimately filed for bankruptcy--all after a private 
equity firm acquired the company.\5\
---------------------------------------------------------------------------
    \2\ National Center for Health Statistics, ``Long-term Care 
Providers and Services Users in the United States, 2015-2016,'' 
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
    \3\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html; Reveal, ``The rats sensed she was 
going to pass away,'' Jennifer Gollan, September 18, 2019, https://
www.revealnews.org/article/elderly-often-face-neglect-in-california-
care-homes-that-exploit-workers/.
    \4\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
    \5\ Washington Post, ``Overdoses, bedsores, broken bones: What 
happened when a private-equity firm sought to care for society's most 
vulnerable,'' Peter Whoriskey and Dan Keating, November 25, 2018, 
https://www.washingtonpost.com/business/economy/opioid-overdoses-
bedsores-and-broken-bones-what-happened-when-a-private-equity-firm-
sought-profits-in-caring-for-societys-most-vulnerable/2018/11/25/
09089a4a-ed14-11e8-baac-2a674e91502b_story.html.

This is particularly concerning given the fact that two-thirds of 
nursing home residents rely on government-sponsored health insurance 
coverage, meaning both not-for-profit and for-profit nursing homes 
benefit from government funding.\6\ Medicaid is the primary payer \7\ 
for nursing home care, with Medicare and Medicaid combined covering 
approximately 75 percent of nursing home residents.\8\ In 2015, 
taxpayers sent more than $55 billion to the nursing home industry to 
cover the costs of long-term care. These reports and corresponding 
research raise serious questions about the role of private equity firms 
in the nursing home care industry, and the extent to which these firms' 
emphasis on profits and short-term return is responsible for declines 
in quality of care. They also raise concerns over the stewardship of 
taxpayer dollars, when--in many cases--these facilities continue to 
receive Medicare and Medicaid funding despite their decline in quality.
---------------------------------------------------------------------------
    \6\ Kaiser Family Foundation, ``Distribution of Certified Nursing 
Facility Residents by Primary Payer Source,'' accessed on Nov. 14, 
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22.%22sort%22:%22asc%22%7D.
    \7\ Kaiser Family Foundation, ``Medicaid's Role in Nursing Home 
Care,'' June 20,2017, https://www.kff.org/infographic/medicaids-role-
in-nursing-home-care/.
    \8\ Kaiser Family Foundation, ``Distribution of Certified Nursing 
Facility Residents by Primary Payer Source,'' accessed on Nov. 14, 
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22.%22sort%22:%22asc%22%7D.

The majority of nursing facilities--almost 70%--are for-profit, and 
over half are chain-affiliated.\9\ The overwhelming majority of 
research conducted over the last 2 decades shows that for-profit and 
chain affiliated\10\ companies provide a lower quality of care and 
experience more serious health and safety deficiencies when compared to 
non-profit facilities.\11\
---------------------------------------------------------------------------
    \9\ National Center for Health Statistics, ``Long-term Care 
Providers and Services Users in the United States, 2015-2016,'' 
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
    \10\ Facilities owned or leased by ``an organization that owns two 
or more long-term care facilities.''
    \11\ International Journal of Health Services, ``Ownership, 
Financing, and Management Strategies of the 10 largest for-profit 
nursing home chains in the United States,'' Charlene Harrington et al., 
2011; Medical Care Research and Review, ``Nursing home profit status 
and quality of care: Is there any evidence of an association?'', 
Michael P. Hillmer et al., April 2005, https://www.ncbi.nlm.nih.gov/
pubmed/15750174.

Additionally, for-profit facilities receive the lowest scores in the 
Centers for Medicare and Medicaid Services' (CMS) nursing home rating 
system that takes into account, state health inspections, staffing 
ratios and quality measures.\12\
---------------------------------------------------------------------------
    \12\ Kaiser Family Foundation, ``Reading the Stars: Nursing Home 
Quality Star Ratings, Nationally and by State,'' May 2015, http://
files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-
quality-star-ratings-nationally-and-by-state.

Private equity investment appears to exacerbate the problems faced at 
chain-
affiliated for-profit nursing homes. Studies show that private equity-
owned facilities generally ``deliver poorer quality of care'' than 
other chain-affiliated for-profit facilities; are likely to try to 
reduce cost by ``substituting expensive but skilled RNs with cheaper 
and less skilled nurses;'' and ``report significantly higher number of 
deficiencies'' that climb with more years of private equity ownership. 
As a result, private equity-owned nursing homes have 21% higher 
deficiencies, 25% lower nursing staff skill mix, and ``worse results on 
pressure sore prevention . . . and [higher] pressure ulcer [] risk 
prevalence.''\13\ That was reportedly the case at HCR ManorCare--the 
second largest for-profit nursing home chain in the United States. In 
the years following its acquisition by a private equity firm, ``the 
number of citations increased for, among other things, neither 
preventing nor treating bed sores; medication errors; not providing 
proper care for people who need special services such as injections, 
colostomies and prostheses; and not assisting patients with eating and 
personal hygiene.''\14\
---------------------------------------------------------------------------
    \13\ Journal of Health Care Finance, ``Private Equity Ownership of 
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
    \14\ Washington Post, ``Overdoses, bedsores, broken bones: What 
happened when a private-
equity firm sought to care for society's most vulnerable,'' Peter 
Whoriskey and Dan Keating, November 25, 2018, https://
www.washingtonpost.com/business/economy/opioid-overdoses-bedsores-and-
broken-bones-what-happened-when-a-private-equity-firm-sought-profits-
in-caring-for-societys-most-vulnerable/2018/11/25/09089a4a-ed14-11e8-
baac-2a674e91502b_story.html.

Moreover, while the quality of service declines, the complicated 
ownership and operating structure of these investments ``limit legal 
remedies available to aggrieved residents.''\15\ For example, after a 
resident died at the private-equity-owned Habana Health Care Center (as 
a result of ``a wound [that] should have been detected much earlier''), 
a family member tried to sue the owners of the facility, only to 
discover that the facility's complicated ownership structure ``meant 
that even if she prevailed in court, the investors' wallets would 
likely be out of reach.''\16\ Shifting funds to other affiliated 
entities, or to the private equity firm itself, to immunize itself from 
liability for judgments against a target company is a widespread 
practice in the private equity industry.
---------------------------------------------------------------------------
    \15\ Journal of Health Care Finance, ``Private Equity Ownership of 
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
    \16\ New York Times, ``At Many Homes, More Profit and Less 
Nursing,'' Charles Duhigg, September 23, 2007, https://www.nytimes.com/
2007/09/23/business/23nursing.html.

Private equity investment in this sector has increased over the last 
few decades. The Government Accountability Office found that over the 
span of 10 years ending in 2008, private investment firms acquired 
approximately 1,900 unique nursing homes.\17\ Today, private equity 
firms own or operate several large for-profit chains that control 
hundreds of facilities and provide nursing home care among other long-
term care services.\18\ Warburg Pincus reportedly owns or has had 
investments in companies providing nursing home care. In order to help 
us understand your firm's role in the nursing home sector, we ask that 
you provide answers to the following questions no later than November 
29, 2019.
---------------------------------------------------------------------------
    \17\ Government Accountability Office, ``Nursing Homes: Complexity 
of Private Investment Purchases Demonstrates Need for CMS to Improve 
the Usability and Completeness of Ownership Data,'' September 2010, 
https://www.gao.gov/assets/320/310562.pdf.
    \18\ IQVIA, ``U.S. Elder Care Market Summary,'' September 2019, 
https://www.skainfo.com/reports/u.s.-elder-care-market-summary.

      1.  Please provide the disclosure documents and information 
enumerated in Sections 501 and 503 of the Stop Wall Street Looting 
Act.\19\
---------------------------------------------------------------------------
    \19\ Stop Wall Street Looting Act, S. 2155, https://
www.congress.gov/bill/116th-congress/senate-bill/2155.

      2.  Which nursing home or other long-term care service companies, 
including all affiliates or related entities, does Warburg Pincus have 
a stake in or own? Please provide the name of and a brief description 
of the services each company provides--including the number of 
---------------------------------------------------------------------------
facilities that it owns or operates.

          a.  Which nursing home or other long-term care companies, 
including all affiliates or related entities, has Warburg Pincus had a 
stake in or owned in the past 20 years? Please provide the name of and 
a brief description of the services each company provides or provided--
including the number of nursing home and other long-term care 
facilities that it owned or operated.

          b.  For each nursing home or other long-term care service 
company Warburg Pincus had a stake in or owned in the past 20 years, 
including all affiliates or related entities, please provide the 
following information for each year that the firm have had a stake in 
or owned this company and the 5 years preceding the firm's investment.

            i.  The name of the company
            ii.  Total number of facilities, by type of facility
           iii.  Ownership stake
           iv.  Total revenue, and the total revenue from Medicare, and 
from Medicaid
           v.  Total transaction, advisory, or other fees collected 
after the acquisition of the company
           vi.  Net income
          vii.  Total number of employees for each facility
          viii.  Total number of patients for each facility, and the 
total number whose care is paid for by Medicare, and by Medicaid
           ix.  Other private-equity firms that own a stake in the 
company

      3.  Private-equity firms reportedly employ sale-leaseback 
arrangements in order to quickly recover investments. For each company 
listed in questions 2(a) and 2(b), please list the number of nursing 
home or other long-term care facilities for which you acquired real 
estate assets, and whether a sale-leaseback agreement has been executed 
for any of those companies or facilities.

      4.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Warburg Pincus 
has an ownership stake or has had an ownership stake in the last 20 
years received Section 232 Department of Housing and Urban Development 
(HUD)-insured mortgages? If so, please provide the name of each 
facility and the total value of each loan insured by HUD.

      5.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Warburg Pincus 
has an ownership stake or has had an ownership stake in the last 20 
years, been placed in receivership? Please provide the name of each 
facility.

      6.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Warburg Pincus 
has an ownership stake or has had an ownership stake in the last 20 
years, been found to have violated any federal or state laws or 
regulations? If so, please provide a complete list, including the date 
and description, of all such violations. Please also include a list of 
all deficiencies identified in state or federal surveys of the 
facilities owned by the company for each year.

      7.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Warburg Pincus 
has an ownership stake or has had an ownership stake in the last 20 
years, reached a settlement with any federal or state law enforcement 
entity related to a potential violation of any federal or state laws or 
regulations or deficiencies in providing care? If so, please provide a 
complete list, including the date and description, of all such 
settlements.

      8.  Has any nursing home or other long-term care company, 
including all affiliates or related entities, in which Warburg Pincus 
has an ownership stake or has had an ownership stake in the past 20 
years, reached a settlement with any individual who was provided 
services by the company related to a potential violation of any federal 
or state laws or regulations or deficiencies in providing care? If so, 
please provide a complete list, including the date and description, of 
all such settlements.

Thank you for your attention to this matter.

            Sincerely,

Elizabeth Warren                    Mark Pocan
United States Senator               United States Congress

Sherrod Brown
United States Senator

                                 ______
                                 
                     Fillmore Capital Partners LLC

                   Four Embarcadero Center, Suite 710

                         San Francisco CA 94111

                            T: 415-834-1477

                            F: 415-834-1475

                      https://www.fillmorecap.com/

December 18, 2019

The Honorable Elizabeth Warren
The Honorable Sherrod Brown
Mark Pocan, Member of Congress
Congress of the United States
Washington DC 20510

    RE: United States Congress--Letter of November 15, 2019

Dear Senator Warren, Senator Brown and Congressman Pocan:

    This will confirm receipt of an electronic copy of your above-
referenced letter directed to Fillmore Capital Partners in which you 
make certain representations about private equity companies and request 
information about Fillmore Capital Partners and affiliates. In 
preparing for response, we explored the basis for your written request 
for detailed proprietary information. I note that in your role as 
Democratic members of the House and Senate you have proposed a bill 
entitled the ``Stop Wall Street Looting Act of 2019'' with the goal of 
enhancing government scrutiny of the private equity sector. Your letter 
to Fillmore Capital Partners advocates for the points you believe 
support passage of the Act and requests information that would 
presumably be used as part of the effort to pass this Act. Please find 
below my response to your letter, which is tailored to your request and 
the circumstances, based on information readily available at this time.

    First, I would like to share a high level review of my observations 
of the nursing home industry as a whole so that we have the proper 
context here. In my opinion it is counterproductive to paint any sector 
with a broad-brush, be it the investment or nursing home sector. I have 
personal experience with the healthcare industry as a caregiver to my 
mom and dad, both veterans of WWII, as well as countless other family 
members and friends. To hold the hand of the dying is both difficult 
and life changing. In addition to my role with Fillmore, I have served 
as a board chairperson for several ownership companies, some of which 
had affiliations with the long-term care industry and the operation of 
nursing homes. These are my general observations as an individual, 
caregiver, trustee of an IDD individual and as a board chairperson.

    It should come as no surprise to you that I disagree with the 
portrayal of individuals and businesses affiliated with the private 
equity sector and nursing home industry as ``uncaring'' and ``profit-
seeking.'' The nursing home industry and healthcare providers in 
general in this Country employ some of the most hardworking and caring 
citizens in the U.S. Every day 24/7/365, healthcare providers touch the 
lives of tens of millions of individuals and families, many of which 
are your constituents, in an attempt to provide care, comfort and 
solutions. With respect to nursing or long-term care, in most cases 
these are patients whose family could not care for them or would not 
care for them. They are patients who were ready to discharge from 
hospitals with no place to go. They are patients with mental and 
physical conditions in need of the services that only a nursing home is 
willing to provide. They are for the most part, our elderly population 
who have little to no income, living on the edge of life with no 
alternatives. For profit and non-profit nursing home operators serve 
our communities whether they be urban, suburban or in rural parts of 
the U.S. Many providers do so with 50 plus year-old facilities, limited 
financial resources, outdated regulations, labor and skill challenges, 
enduring general disdain from the uninformed. As my Marine Corps mother 
said at 87, ``getting old ain't for the faint of heart.'' Nursing home 
operators have provided services in States with Medicaid reimbursement 
rates that do not even cover the actual costs of the care provided to 
citizens of their State, yet operators have often continued to provide 
the resources needed to support those locations. In some communities 
the nursing facility is the only healthcare resource, the largest 
employer, and even provides coffee for local first responders. Nursing 
homes, and the caregivers in them, have served and continue to serve as 
a critical resource for the elderly and infirm U.S. population.

    As you are aware, effective in 2012 Congress reduced planned 
Medicare reimbursement rates for nursing homes in by 11.1%. At the time 
the then President of the Alliance for Quality Nursing Home Care stated 
that lawmakers would as a result be ``faced with an increased threat to 
local seniors' access to care.'' Recent closure of nursing facilities 
in rural areas in multiple States has in fact threatened seniors' 
access to care. Without question rural communities will continue to 
struggle with access to healthcare, long-term care, medication 
management and hospice care. Industry leaders with whom I have spoken, 
have grave concerns regarding how the future needs of the baby boomer 
elderly will be met given the current lack of Federal and State support 
for the nursing home industry in the U.S. Adequate funding is needed to 
help your constituents who have to rely on government funding to 
receive care. Much like the aging infrastructure issue this Country 
faces with regard to housing for those with low income, the physical 
plant locations for many nursing homes are reaching the end of their 
useful life. Industry leaders have cautioned that given the current 
economic realities, even with State, Federal and private sector 
support, it is doubtful that providers will be able to develop new or 
replace old facilities. It cannot be disputed that the industry is 
already one of the most heavily regulated, scrutinized and targeted for 
litigation in the Country. Without changes in reimbursement to offset 
escalating costs overall, many facilities that are needed by the senior 
population simply will not survive.

    With regard to your specific requests for information, the first 
requests information that could be required in the event the Act were 
passed. Because the Act has not passed we are not educated about the 
requirements of the Act and are not in a position to respond to this 
request. The response to request #2(a) is simple and is already known 
to CMS and most State SNF licensure authorities. The response to 
requests #2(b) through #8 involves asking affiliates of Fillmore 
Capital to gather a significant amount of information, much of which 
has already been provided to government agencies and is otherwise 
publicly available. As of this date the Fillmore and Golden Living 
affiliated Golden Living Center operators no longer operate nursing 
homes. Therefore, those affiliates have limited personnel to locate and 
retrieve the information requested. I can, however, provide some basic 
information that I have obtained, such as for #4 I am not aware of any 
HUD financing related to Golden Living Centers; for #5, no Golden 
Living Center licensed operator was placed in receivership at any time; 
for #6, very few, if any, operators could answer `no' as the nursing 
home industry is very heavily regulated and frequently assessed fines 
for alleged violations. CMS has public data readily available to you 
from which you can identify nursing facility surveys. #7 and #8 request 
information subject to confidentiality obligations which our affiliates 
with very limited resources would have to research.

    I have noticed that numerous references cited in your letter are 
sources that have for many years criticized and opposed both nursing 
home operators and their affiliated holding companies/owners. They have 
pure disdain for what caregivers do, many in aging facilities with few 
modern amenities. Of course, nursing home providers care for your 
Medicaid constituents, generally frail and declining with numerous 
health challenges 24/7/365 for less than $140 per day and, as my mother 
would once again say, that ain't for the faint of heart! I hope you 
will find this response beneficial. I am willing to make time to 
further discuss this and attempt to create understanding in order to 
replace disdain. It is also my understanding that there are many 
nursing home operator representatives who are willing to work closely 
with Congress to share information and pursue solutions that are in the 
overall best interest of your constituents.

    Finally, as an example of the positive impact investors can have on 
the healthcare industry, please review the websites of two Fillmore 
affiliated healthcare organizations which are defying the odds to 
successfully provide needed state-of-the-art services, www.Salude.com 
and www.alixarx.com. Salude is a specially constructed skilled nursing 
facility which is ranked by CMS as the #1 skilled nursing care facility 
in the U.S., out of 15,000 nationally. AlixaRx is a unique remote 
automated pharmacy solution developed for nursing care, to make needed 
medications more readily available in rural communities by providing 
on-demand medication and patient medication management. Unfortunately, 
these concepts are not likely to come to your communities soon as they 
require financial resources beyond what are currently available in most 
States and communities in order to succeed.

            With Respect,

            Ronald E. Silva
            President and CEO

                                 ______
                                 

                               Akin Gump

                       strauss hauer and feld llp

                           RAPHAEL A. PROBER

                     202-887-4319/fax: 202-887-4288

                          [email protected]

                    confidential treatment requested

                           November 29, 2019

VIA E-MAIL

The Honorable Elizabeth Warren
United States Senate
9 Hart Senate Office Building
Washington, DC 20510

The Honorable Sherrod Brown
United States Senate
503 Hart Senate Office Building
Washington, DC 20510

The Honorable Mark Pocan
United States House of Representatives
1421 Longworth House Office Building
Washington, DC 20510

Re: November 15, 2019 Letter to Warburg Pincus, LLC

Dear Senator Warren, Senator Brown, and Congressman Pocan:

On behalf of Warburg Pincus, LLC (``Warburg Pincus''), we write in 
response to your letter dated November 15, 2019 (the ``Letter'') in 
which you requested information regarding investments made by funds 
managed by Warburg Pincus in skilled nursing facilities.

Funds managed by Warburg Pincus, since its founding in 1966, have made 
over 150 healthcare investments. In the last 20 years, only two 
investments made by funds managed by Warburg Pincus were in the skilled 
nursing home care industry; the first of which was exited in 2002 and 
the second of which was exited in 2011. Since 2011, no fund managed by 
Warburg Pincus has made or held any investments in skilled nursing 
facilities. Below, please find information on the investments exited in 
2002 and 2011, which constitute the only investments covered by your 
Letter.\1\
---------------------------------------------------------------------------
    \1\ Funds managed by Warburg Pincus also invested in two companies 
focused on the assisted living industry, Brandywine Senior Care 
(invested in 2006, exited in 2010) and The Covenant Group (invested in 
2007, exited in 2011).

Since its founding in 1966, Warburg Pincus has predominantly pursued a 
strategy of growth investing at scale, with the vast majority of the 
investments made in growth stage or early stage companies. Over the 
years, funds managed by Warburg Pincus have successfully invested in 
growth companies as well as companies at other stages of development, 
from building early-stage and start-up companies, to providing capital 
to meet the needs of existing businesses and, to a lesser extent, to 
investing in later-stage transactions and special situations, typically 
in circumstances in which growth is a key aspect of the investment 
thesis. The firm's early-stage and growth investing approach is thesis-
driven, pursuing extensively researched themes and ideas. The firm also 
prefers to invest with accomplished management teams who are investing 
in the transactions alongside the firm. As evidence of the firm's 
successful focus on growth investing, the firm's portfolio investments 
---------------------------------------------------------------------------
have completed over 170 initial public offerings.

Warburg Pincus aims to build lasting companies that will perform well 
in growing industries--the goal in every investment is to create a 
larger, thriving business by making long-term investments and creating 
value. Warburg Pincus believes that this approach positions the 
investors in the funds it manages, which include pension funds that 
benefit multiple categories of public and private employees, to receive 
attractive risk-adjusted long-term returns over the course of economic 
and capital markets cycles.

In 2000, funds managed by Warburg Pincus invested in Centennial 
Healthcare Corporation (``Centennial''). At the time, Centennial was a 
publicly traded operator of approximately 100 skilled nursing 
facilities, of which 6 were owned, 64 were leased, and 30 were managed, 
and had operations in 22 states. During that period, the skilled 
nursing home care industry was severely challenged due to, among other 
things, reduced reimbursement rates, high leverage, high labor costs 
due to a labor shortage, and high litigation expenses due to industry-
wide regulatory issues and increasing patient liability tort claims. 
Four of the seven largest home chains had filed for bankruptcy, with a 
fifth imminent (which subsequently also filed for bankruptcy). 
Centennial itself faced these challenges. Warburg Pincus's investment 
thesis was that the industry was poised to recover due to, among other 
things, an increasing demand for long-term nursing care because of an 
aging population. In light of that investment thesis, funds managed by 
Warburg Pincus acquired approximately 52% of Centennial in 2000, with 
management and other investors (Welsh Carson and South Atlantic 
Capital) owning the rest. Despite management's efforts to turn 
Centennial around in this challenging environment, the company filed 
for bankruptcy in 2002. No dividends were paid to any fund managed by 
Warburg Pincus during the period of ownership, nor did Warburg Pincus 
itself charge or collect any transaction, advisory or other fees, 
consistent with the firm's long-standing practice not to charge such 
fees for any services provided by Warburg Pincus employees to portfolio 
companies.

Based on the same investment thesis for Centennial, funds managed by 
Warburg Pincus co-founded Florida Healthcare Properties (``Florida 
Healthcare'') in 2001, owning approximately 75% of the company during 
much of its ownership tenure, with other health care executives and 
management owning the rest. Over time, Florida Healthcare came to 
operate approximately 127 skilled nursing facilities in 17 states and 
the District of Columbia. Sale-leasebacks were not part of the 
company's business model--the company leased almost all of its 
facilities from third parties. The funds managed by Warburg Pincus 
exited their investment in Florida Healthcare in 2011. (The company's 
name had since been changed to Lavie Care Centers.) Once again, Warburg 
Pincus did not charge or collect any transaction, advisory or other 
fees.

Warburg Pincus's involvement in the operations of its portfolio 
companies, like Centennial and Florida Healthcare, is that of an 
investor. While Warburg Pincus nominees often sit on the boards of 
directors of its portfolio companies (and held seats on the boards of 
directors of both Centennial and Florida Healthcare during the periods 
of ownership), the role and responsibility of such board 
representatives is one of oversight of the company's executive 
management team and assistance in the strategic direction of the 
company. The executive management teams of portfolio companies are 
responsible for the day-to-day operations of the portfolio companies. 
As a general matter, the information provided to board members is 
designed to assist them in discharging their oversight duties.

We hope the information that Warburg Pincus has provided herein with 
respect to the two investments exited nearly a decade ago is helpful to 
your review.

                               * * * * *

The information and data included in this response contains sensitive 
information--including confidential and proprietary information--and we 
request that such information be treated accordingly and that it not be 
released to any third parties. Production of this information and data 
is not intended to constitute a waiver of the attorney-client, attorney 
work product, or any other applicable rights or privileges in this or 
any other forum, and Warburg Pincus expressly reserves its rights in 
this regard.

            Sincerely,

            Raphael A. Prober
            Counsel for Warburg Pincus
                                 ______
                                 
                           The Carlyle Group

                1001 Pennsylvania Avenue, NW, Suite 220

                       Washington, DC 20004-2505

                 Tel (202) 729-5626 Fax (202) 347-1818

                        https://www.carlyle.com/

November 29, 2019

Senator Elizabeth Warren
309 Hart Senate Office Building
Washington, DC 20510-4543

Senator Sherrod Brown
503 Hart Senate Office Building
Washington, DC 20510-4543

Congressman Mark Pocan
1421 Longworth House Office Building
Washington, DC 20510-4543

Dear Senators Warren, Brown and Congressman Pocan:

We received your inquiry dated November 15, 2019 regarding The Carlyle 
Group's investments in companies providing nursing home care and other 
long-term care services. We appreciate your interest in the subject.

The Carlyle Group (``Carlyle'') is a global investment firm with deep 
industry expertise that deploys private capital across four business 
segments: Corporate Private Equity, Real Assets, Global Credit, and 
Investment Solutions. With $222 billion of assets under management, 
Carlyle's purpose is to invest wisely and create value on behalf of its 
investors, many of whom are public pensions. Carlyle has expertise in 
various industries, including aerospace, defense and government 
services, consumer and retail, energy and power, financial services, 
healthcare, industrial, real estate, technology and business services, 
telecommunications and media, and transportation. The portfolio 
companies owned by Carlyle investment funds employ 900,000 people 
globally and more than 100,000 in the United States. Since its founding 
in 1987, the firm has invested $103 billion in 643 Corporate Private 
Equity transactions. More than 2,600 investors from 94 countries 
entrust Carlyle with their capital.

The healthcare sector has been a core focus area for Carlyle for over 
25 years. Carlyle's investments in healthcare companies have spanned 
geographies--including North America, Europe, South America, and Asia--
and subsectors within healthcare--including leading providers of 
clinical care, preeminent research organizations, reliable 
manufacturers of medical devices and pharmaceutical products, and 
reputable service providers that facilitate access to timely and high-
quality care. Our portfolio of investments, within healthcare and 
across other industries, also spans investment strategies, including 
investing in growth-oriented companies to support their expansions. 
Regardless of the geography, subsector, or investment strategy, we seek 
to invest behind healthcare companies that can capitalize on growth 
opportunities, drive better health outcomes for patients, and bring 
improvements to the healthcare system. As part of our investment 
process, we also evaluate the environmental, social, and governance 
aspects of a company, which takes into consideration key stakeholders, 
including patients, payors, customers, and employees.

Today, neither Carlyle nor any nor its investment funds owns any equity 
interest in any company that operates nursing facilities \1\ in the 
United States.\2\ In 2007, an investment fund managed by Carlyle 
acquired a majority equity investment in HCR ManorCare, Inc. (``the 
Company'' or ``HCR''), which operated skilled nursing, assisted living 
and home healthcare facilities. Carlyle never managed the operations of 
the company. However, employees of Carlyle served as members of the 
Board of Directors of HCR, and the Board of Directors ensured that the 
Company had appropriate policies and procedures in place to assess and 
address clinical quality at HCR's facilities. For example, under 
Carlyle's ownership, HCR ManorCare established an Independent Advisory 
Committee on Quality, which provided advice and recommendations to the 
Company's Board of Directors on ways to measure, maintain and improve 
quality care for HCR ManorCare patients and residents.
---------------------------------------------------------------------------
    \1\ See the Nursing Home Compare site of medicare.gov: ``Nursing 
home is a term that includes both skilled nursing facilities and 
nursing facilities. Skilled nursing facilities (SNF) are those that 
participate in both Medicare and Medicaid. Nursing facilities (NF) arc 
those that participate in Medicaid only. Nursing homes primarily engage 
in providing residents skilled nursing care and related services for 
residents who require medical or nursing care and rehabilitation 
services for the rehabilitation of injured, disabled, or sick 
individuals.'' (https://www.
medicare.gov/NursingHomeCompare/Resources/Glossary.html)
    \2\ Carlyle Real Estate funds do hold investments in real estate on 
which private pay senior living communities, independent communities 
and assisted living communities are operated. However, the companies in 
which Carlyle's Real Estate funds hold investments do not operate these 
facilities.

During Carlyle's ownership, quality and care delivery remained a key 
priority for the Company.\3\ From 2007-2017, HCR's total staffing, 
hands on caregiving staff and nursing staff all increased. The Centers 
for Medicare and Medicaid Services (``CMS'') rated HCR ManorCare's 
regulatory compliance above industry average. At the time of Carlyle's 
exit, HCR ManorCare's CMS Five Star Rating \4\ Data show that the 
facilities were at or above industry average for overall, quality 
measures, staffing and registered nurse staffing. In fact, most of the 
centers received four or five stars. From 2013-2017, HCR ManorCare's 
serious safety incident rate was better than the national average in 
each and every year. During the same period, the average CMS quality 
measure star rating was considered outstanding by CMS, with 88% of 
centers receiving four or five stars.
---------------------------------------------------------------------------
    \3\ All data referenced in this letter provided to Carlyle by HCR 
ManorCare.
    \4\ The Centers for Medicare and Medicaid Services created the 
Five-Star Rating System to allow consumers to assess nursing homes on 
health inspections, staffing and quality measures.

Management of real estate assets is a necessary part of operating in 
the nursing facility industry, and, during Carlyle's ownership, HCR, 
like other companies in the industry, engaged in a number of 
transactions involving its real estate holdings. Those transactions 
included a 2011 sale-lease-back transaction in which HCP, Inc. acquired 
a portion of HCR's real estate assets and leased those facilities back 
to HCR. HCP, Inc. subsequently transferred those assets to Quality Care 
---------------------------------------------------------------------------
Properties, Inc.

Following our initial investment, several legislative events and CMS 
actions created reimbursement headwinds that negatively impacted the 
company's financial performance. These measures reduced the company's 
reimbursement and/or increased its costs by hundreds of millions of 
dollars. As an example, Medicare rates for the industry and HCR for 
2019 are lower than they were in 2011 due to rate cuts and changes in 
rate methodology. The entire skilled nursing facility industry has been 
negatively affected by these changes. In fact, The Medicare Payment 
Advisory Committee (MedPAC), the agency that provides the U.S. Congress 
with analysis and policy advice, estimated the margin for the entire 
skilled nursing facility industry was less than 1.0% in 2017.\5\ 
Numerous other companies in the industry have filed for bankruptcy, 
exited long-term care or were financially distressed during this time, 
including Genesis, Signature, Extendicare, Skyline, Kindred, Golden 
Living and Consulate.
---------------------------------------------------------------------------
    \5\ Per MedPAC March 2019 Report to Congress.

Given these changes in reimbursement, HCR ManorCare had been working on 
a plan to recapitalize its balance sheet in a manner designed to 
promote the long-term financial health of the Company and maintain 
quality of care. For legal reasons, the company filed for pre-packaged 
bankruptcy in 2018. Patient care was not compromised. All creditors and 
employees continued to be paid during the bankruptcy proceedings and 
not a single creditor (other than the Company's landlord, Quality Care 
Properties) lost capital as a result of the bankruptcy filing. As a 
result of this restructuring, HCR ManorCare became a wholly owned 
subsidiary of ProMedica Health System in 2018. Carlyle owns no interest 
in either HCR ManorCare or ProMedcia. ProMedica, an acute care health 
system, bought HCR ManorCare because it is a high-quality provider. 
ProMedica would not have acquired HCR if it did not believe that HCR 
---------------------------------------------------------------------------
provides high quality patient care.

Carlyle takes pride in its approach to responsible investing. We thank 
you for your inquiry in this subject.

Sincerely,

Stacey Dion
Managing Director, Global Government Affairs

                                 ______
                                 
                Prepared Statement of Hon. Mike Crapo, 
                       a U.S. Senator From Idaho
    At the national, State and local levels, the pandemic has 
challenged our sense of normalcy. It has tested every institution of 
daily life we know, threatening the physical and economic health of our 
Nation. Americans from all walks of life have experienced a year full 
of tremendous hardship and tragedy. It is the people living and working 
in our Nation's nursing homes, however, who bore an outsized burden.

    More than 174,000 people died as COVID-19 ravaged our long-term 
care facilities. That number represents almost one-third of all U.S. 
deaths that have occurred during the pandemic.

    Both long-stay nursing homes and short-stay post-acute skilled 
nursing facilities rely on direct care workers--such as licensed 
practical nurses, certified nursing assistants, and personal care 
aides--to provide most hands-on care. These workers are in close 
physical contact with residents, assisting with bathing, dressing, and 
eating. Current data shows that long-term care workers are typically 
female, and a disproportionate share are women of color.

    Many of these direct care workers live paycheck to paycheck. Over 
the past year, they have put their lives on the line. We owe them a 
debt of gratitude. Thank you to the dedicated nursing home workers like 
Adelina Ramos, one of our witnesses.

    These workers hear Americans calling them heroes, but they are 
often under-
appreciated when on the job. To these front-line workers, please know 
that the sacrifices you are making every day do not go unnoticed or 
unappreciated.

    Today, we will hear from a number of expert witnesses who will 
provide key insights into nursing home conditions over the past year. 
This testimony will help us better understand exactly what happened, 
when it happened, and why it happened. It will give us insight into 
policies that produced results, as well as areas that need improvement.

    Hearings are just one oversight tool this committee uses to hold 
government agencies, the health-care industry, and individual providers 
accountable. Another key part of oversight is securing reliable and 
accurate data. Transparent data reporting brings accountability and 
helps drive decision-making. As we look to the future, it is vital that 
all States report accurate COVID-19 data. That is the only way for 
economists, researchers, advocacy organizations, and policy-makers to 
tackle the challenges facing the nursing home sector head-on.

    This is not a job for the Federal Government alone. Multiple 
Federal, State, and local programs and partnerships work to support the 
health-care needs of our Nation's most vulnerable populations. We must 
work together--in an honest and transparent manner--to safeguard our 
nursing home residents and the workers who care for them.

    Over the weekend, The New York Times published the results of an 
investigation into the Centers for Medicare and Medicaid Services (CMS) 
nursing home five-star rating system. The investigation questions the 
objectivity and accuracy of the CMS star ratings system. This rating 
system, which was first implemented during the Obama administration, is 
designed to help beneficiaries, their families, and caregivers compare 
nursing home quality more easily.

    Care Compare is another online tool available to help seniors, the 
disabled, and their families find out if a particular nursing home 
facility meets Federal health and safety standards, staffing levels, 
and quality performance metrics.

    After several bipartisan hearings held by the Finance Committee 
during 2019, CMS implemented changes to Nursing Home Compare that 
specifically denote nursing homes that have been cited for incidents of 
abuse, neglect, or exploitation. That may have been a start, but 
clearly there is a lot more work that needs to be done.

    I am grateful to each of our witnesses for the work that they are 
doing and for taking the time to join us today. Their expertise will 
help us advance public policies that slow the spread of COVID-19 and 
lessen its devastating impacts on our Nation's elderly and the 
disabled.

                                 ______
                                 
            Prepared Statement of John E. Dicken, Director, 
             Health Care, Government Accountability Office

COVID-19 in Nursing Homes: HHS Has Taken Steps in Response to Pandemic, 
       but Several GAO Recommendations Have Not Been Implemented

Why GAO Did This Study

    The COVID-19 pandemic has had a disproportionate impact on the 1.4 
million elderly or disabled residents in the Nation's more than 15,000 
Medicare- and 
Medicaid-certified nursing homes, who are often in frail health and 
living in close proximity to one another. HHS, primarily through CMS 
and CDC, has led the pandemic response in nursing homes.

    The CARES Act includes a provision for GAO to conduct monitoring 
and oversight of the Federal Government's efforts to prepare for, 
respond to, and recover from the COVID-19 pandemic. GAO has examined 
the government's response to COVID-19 in nursing homes through its 
CARES Act reporting (GAO-21-265, GAO-21-191, GAO-20-701, and GAO-20-
625).

    This testimony will summarize the findings from these reports. 
Specifically, it describes COVID-19 trends in nursing homes and their 
experiences responding to the pandemic, and HHS's response to the 
pandemic in nursing homes.

    To conduct this previously reported work, GAO reviewed CDC data, 
agency guidance, and other relevant information on HHS's response to 
the COVID-19 pandemic. GAO interviewed agency officials and other 
knowledgeable stakeholders. In addition, GAO supplemented this 
information with updated data from CDC on COVID-19 cases and deaths 
reported by nursing homes as of February 2021.

What GAO Found

    GAO's review of data from the Centers for Disease Control and 
Prevention (CDC) found that winter 2020 was marked by a significant 
surge in the number of COVID-19 cases and deaths in nursing homes. 
However, CDC data as of February 2021, show that both cases and deaths 
have declined by more than 80 percent since their peaks in December 
2020. With the introduction of vaccines, observers are hopeful that 
nursing homes may be beginning to see a reprieve.Nevertheless, the 
emergence of more highly transmissible virus variants warrants the need 
for continued vigilance, according to public health officials.

    GAO's prior work has found that nursing homes have faced many 
difficult challenges battling COVID-19. While challenges related to 
staffing shortages have persisted through the pandemic, challenges 
related to obtaining Personal Protective Equipment (PPE) and conducting 
COVID-19 tests--although still notable--have generally shown signs of 
improvement since summer 2020. Further, with the decline in nursing 
homes cases, the Centers for Medicare and Medicaid Services (CMS) 
updated its guidance in March 2021 to expand resident visitation, an 
issue that has been an ongoing challenge during the pandemic. Some new 
challenges have also emerged as vaccinations began in nursing homes, 
such as reluctance among some staff to receive a COVID-19 vaccine.

    The Department of Health and Human Services (HHS), primarily 
through CMS and the CDC, has taken steps to address COVID-19 in nursing 
homes. However, HHS has not implemented several relevant GAO 
recommendations, including:

      HHS has not implemented GAO's recommendation related to the 
Nursing Home Commission report, which assessed the response to COVID-19 
in nursing homes. CMS released the Nursing Home Commission's report and 
recommendations in September 2020. When the report was released, CMS 
broadly outlined the actions the agency had taken, but the agency did 
not provide a plan that would allow it to track its progress. GAO 
recommended in November 2020 that HHS develop an implementation plan. 
As of February 2021, this recommendation had not been implemented.

      HHS has not implemented GAO's recommendation to fill COVID-19 
data voids. CMS required nursing homes to begin reporting the number of 
cases and deaths to the agency effective May 8, 2020. However, CMS made 
the reporting of the data prior to this date optional. GAO recommended 
in September 2020 that HHS develop a strategy to capture more complete 
COVID-19 data in nursing homes retroactively back to January 1, 2020. 
As of February 2021, this recommendation had not been implemented.

    Implementing GAO's recommendations could help address some of the 
challenges nursing homes continue to face and fill important gaps in 
the Federal Government's understanding of, and transparency around, 
data on COVID-19 in nursing homes. In addition to monitoring HHS's 
implementation of past recommendations, GAO has ongoing work related to 
COVID-19 outbreaks in nursing homes and CMS's oversight of infection 
control and emergency preparedness.
_______________________________________________________________________

    Chairman Wyden, Ranking Member Crapo, and members of the committee:

    I am pleased to be here today to discuss our work on Coronavirus 
Disease 2019 (COVID-19) in nursing homes. Just over a year ago, a 
Washington State nursing home was battling one of the first major 
COVID-19 outbreaks in the United States. Today, the COVID-19 pandemic 
has reached nearly all of the more than 15,000 Medicare- and Medicaid-
certified nursing homes in the country, resulting in a 
disproportionately high number of COVID-19 deaths among residents. 
While the Nation's 1.4 million nursing home residents are a small share 
of the total U.S. population (less than 1 percent), they comprise 
nearly 30 percent of COVID-19 deaths reported by the Centers for 
Disease Control and Prevention (CDC). Nursing home residents are at a 
high risk for COVID-19 infection and death because the virus has a high 
mortality rate among elderly adults and those with underlying health 
conditions. In addition, the congregate nature of nursing homes, with 
staff caring for multiple residents and shared communal spaces, as well 
as high incidence rates in the surrounding community, can increase the 
risk that COVID-19 will enter the home and easily spread. Further, 
efforts to reduce the spread of COVID-19 in nursing homes have required 
changes in typical nursing home practices--such as restricting visitors 
and isolating residents exposed to COVID-19--raising concerns for 
vulnerable residents, who may have less social interaction and third 
party oversight of their care.

    The Centers for Medicare and Medicaid Services (CMS), an agency 
within the Department of Health and Human Services (HHS), is 
responsible for ensuring that nursing homes meet Federal quality 
standards to participate in the Medicare and Medicaid programs.\1\ In 
response to the pandemic, HHS, primarily through CMS and CDC, has taken 
a series of actions with nursing homes, such as providing guidance, 
developing targeted inspections to improve infection control practices, 
and distributing testing devices to homes.\2\ In addition, in May 2020, 
CDC began collecting weekly COVID-19 data from nursing homes through 
its National Healthcare Safety Network system.
---------------------------------------------------------------------------
    \1\ To monitor compliance with these standards, CMS enters into 
agreements with State survey agencies in each State government to 
conduct inspections, including recurring comprehensive standard surveys 
and as-needed investigations. CMS's Center for Clinical Standards and 
Quality has responsibility for overseeing State survey agencies' survey 
and certification activities, among others.
    \2\ In our May 2020 report, we found that infection control 
deficiencies were widespread and persistent in nursing homes in the 
years prior to the COVID-19 pandemic. See GAO, Infection Control 
Deficiencies Were Widespread and Persistent in Nursing Homes Prior to 
COVID-19 Pandemic, GAO-20-576R, (Washington, DC: May 20, 2020).

    The CARES Act includes a provision for us to conduct monitoring and 
oversight of the Federal Government's efforts to prepare for, respond 
to, and recover from the COVID-19 pandemic.\3\ In response to the CARES 
Act, we have examined the response to COVID-19 in nursing homes in four 
reports since June 2020. To help inform today's discussion, my 
testimony will summarize our findings on nursing home issues from these 
reports.\4\ In particular, my statement will address:
---------------------------------------------------------------------------
    \3\ Pub. L. No. 116-139, Sec. 19010(b), 134 Stat. 281, 579 (2020).
    \4\ See GAO, COVID-19: Critical Vaccine Distribution, Supply Chain, 
Program Integrity, and Other Challenges Require Focused Federal 
Attention, GAO-21-265 (Washington, DC: January 28, 2021); COVID-19: 
Urgent Actions Needed to Better Ensure an Effective Federal Response, 
GAO-21-191 (Washington, DC: November 30, 2020); COVID-19: Federal 
Efforts Could Be Strengthened by Timely and Concerted Actions, GAO-20-
701 (Washington, DC: September 21, 2020); and COVID-19: Opportunities 
to Improve Federal Response and Recovery Efforts, GAO-20-625 
(Washington, DC: June 25, 2020).

    1.  COVID-19 trends in nursing homes and their experiences 
---------------------------------------------------------------------------
responding to the COVID-19 pandemic, and

    2.  HHS's response to the COVID-19 pandemic in nursing homes.

    In addition, I will highlight key actions that we recommended HHS 
take and the current status of those recommendations. While my comments 
today focus on the findings of our CARES Act reports, they are also 
informed by our longer-term body of work examining nursing home 
oversight and quality prior to the pandemic.

    To conduct the work for the previously issued reports on which my 
comments are based, we reviewed CDC data, agency guidance, and other 
relevant information on HHS's response to the COVID-19 pandemic. We 
interviewed agency officials, as well as researchers with experience in 
infection control, advocates for individuals residing in nursing homes 
and their families, national associations representing nursing homes, 
and representatives from associations representing State and local 
officials. More detailed information on our methodology can be found in 
the issued reports.\5\ In addition, we supplemented this information 
with updated data from CDC on COVID-19 reported by nursing homes for 
the week ending February 7, 2021.\6\ We analyzed the CDC data as they 
were reported by nursing homes to CDC and publicly posted by CMS. We 
did not otherwise independently verify the accuracy of the information 
with these nursing homes. We assessed the reliability of the data sets 
used in our analyses by checking for missing values and obvious errors 
and reviewing relevant CMS and CDC documents. We determined the data 
were sufficiently reliable for the purposes of our reporting objective.
---------------------------------------------------------------------------
    \5\ For example, see GAO-21-265.
    \6\ We analyzed the most recent data available on February 18, 
2021. The CDC data on COVID-19 in nursing homes were accessed on 
February 18, 2021, for the week ending February 7, 2021, from https://
data.cms.gov/Covid19-nursing-home-data. For the data on COVID-19 in 
nursing homes, we analyzed and reported data that had been determined 
by CDC and CMS to pass quality assurance checks for data entry errors. 
According to CDC, data used in this analysis are part of a live data 
set, meaning that facilities can make corrections to the data at any 
time.

    We conducted the work on which this statement is based in 
accordance with generally accepted government auditing standards. Those 
standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe that 
the evidence obtained provides a reasonable basis for our findings and 
conclusions based on our audit objectives.
   nursing home covid-19 cases and deaths are declining after winter 
        surge; persistent challenges remain in pandemic response
After a Winter Surge, CDC Data Show a Decline in COVID-19 Cases and 
        Deaths Among Nursing Home Residents and Staff to Levels Closer 
        to Those of Fall 2020
    Our analysis of CDC data shows that winter 2020 was marked by a 
significant surge in the number of COVID-19 cases and deaths for 
nursing home residents and staff. Specifically, during mid-December 
2020, there were more than 33,600 new resident cases and 28,600 new 
staff cases, which was more than twice as high as the prior case number 
peaks in summer 2020. CDC data show that cases and deaths in nursing 
homes are on the decline. Specifically, as of the week ending February 
7, 2021, resident and staff cases have both declined by more than 80 
percent since their peaks in December 2020. The changing weekly COVID-
19 death counts in nursing homes generally moved in the same direction 
as changes in the country as a whole. With the introduction of 
vaccines, observers are hopeful that nursing homes may be beginning to 
see a reprieve; however, the emergence of more highly transmissible 
virus variants warrants the need for continued vigilance, according to 
public health officials.\7\ (See fig. 1).
---------------------------------------------------------------------------
    \7\ These numbers are likely underreported because they do not 
include data for the 998 nursing homes (6.5 percent) that did not 
report COVID-19 data to CDC for the week ending February 7, 2021, or 
that submitted data that failed data quality assurance checks. The week 
ending May 31, 2020 is the first single week of data reported to CDC. 
The week ending May 24th is the only earlier week of data, and could 
potentially include cases and deaths for multiple weeks dating back to 
January 1, 2020, for those homes which voluntarily reported such data. 
It is therefore not comparable with data for other weeks, and we 
excluded it. According to CDC, data used in this analysis are part of a 
live data set, meaning that facilities can make corrections to the data 
at any time.

[GRAPHIC] [TIFF OMITTED] T1721.025


    .epsNotes: Dates refer to the end of a week (e.g., May 31 refers to 
---------------------------------------------------------------------------
the entire week from May 25th through May 31st).

    According to CDC, data used in this analysis are part of a live 
data set, meaning that facilities can make corrections to the data at 
any time. Data presented reflect the data downloaded as of February 18, 
2021, which includes data through the week ending February 7, 2021. We 
excluded data for the week ending May 24, 2020, because it is the first 
week for which data are available from the CDC and could include cases 
and deaths from multiple weeks dating back to January 1, 2020.

    Weekly and cumulative case and death counts are likely 
underreported because they do not include data for the nursing homes 
that did not report COVID-19 data to CDC for that week or from nursing 
homes that submitted data that failed data quality assurance checks. 
Additionally, as we previously reported, the Centers for Medicare and 
Medicaid Services (CMS) does not require nursing homes to report data 
prior to May 2020, although nursing homes may do so voluntarily. We 
recommended that the Secretary of Health and Human Services-in 
consultation with CMS and CDC-develop a strategy to capture more 
complete data on confirmed COVID-19 cases and deaths in nursing homes 
retroactively to January 1, 2020. See GAO, COVID-19: Federal Efforts 
Could Be Strengthened by Timely and Concerted Actions, GAO-20-701 
(Washington, DC: September 21, 2020).

    Weekly staff deaths reported for the weeks ending May 31st through 
February 7th ranged from 13 (week ending September 20, 2020) to 61 
(week ending May 31, 2020).
Some Challenges Nursing Homes Faced Persisted While Other New 
        Challenges Have Emerged
    In our prior CARES Act reports, we found that nursing homes have 
faced many difficult challenges battling COVID-19.\8\ While challenges 
related to staffing shortages have persisted through the pandemic, 
challenges related to obtaining Personal Protective Equipment (PPE) and 
conducting COVID-19 tests--although still notable--have generally shown 
signs of improvement since summer 2020. Further, with the decline in 
nursing home cases, CMS updated its guidance in March 2021 to expand 
resident visitation, an issue that has been an ongoing and persistent 
challenge during the pandemic. Some new challenges have also emerged as 
vaccinations started for nursing home residents and staff. (See table 
1). Some of these challenges, such as staffing shortages, obtaining 
PPE, and conducting testing, are critically important for infection 
control.
---------------------------------------------------------------------------
    \8\ See GAO-20-701; GAO-21-265; GAO-21-191; and GAO-20-625.


      Table 1: Key Pandemic Challenges Experienced by Nursing Homes
------------------------------------------------------------------------
  Challenge                 Description                     Status
------------------------------------------------------------------------
Visitation     Through interviews with researchers,  Challenge has
                advocacy organizations, and           persisted
                national association officials from   throughout
                July 2020 to February 2021, we        pandemic
                consistently heard that nursing
                homes have faced an ongoing tension
                between providing residents with
                important visitation and minimizing
                the potential for a COVID-19
                outbreak:
 
                The restriction of visitors has
                negatively affected residents'
                mental and physical health.
                Researchers and advocacy
                organizations have noted that the
                isolation resulting from decreased
                visitation can cause loneliness,
                anxiety, and depression among
                residents.
 
                The restriction of visitors has
                created limited oversight of
                facilities through the exclusion of
                resident advocates, such as family
                members and ombudsmen.
------------------------------------------------------------------------
Staffing       In our reviews of data from the       Challenge has
                Centers for Disease Control and       persisted
                Prevention (CDC) and interviews       throughout
                with advocacy organization and        pandemic
                national association officials from
                July 2020 through January 2021, we
                consistently found that nursing
                home staffing challenges were
                difficult and ongoing throughout
                the pandemic:
 
                CDC data from July through
                December 2020 consistently show
                that about one in five nursing
                homes were reporting to CDC that
                they had a shortage of nurse aides
                or other support staff.a
 
                From nursing home associations we
                interviewed, we heard that many
                alternative staffing sources have
                been used to fill critical gaps,
                such as seeking help from staffing
                agencies, sharing staff between
                other local providers, and using
                emergency waivers to hire nurse
                aides who had yet to complete their
                certification. As of January 2021,
                we continued to hear that staff are
                exhausted, face burn-out from
                emotional trauma, need to
                quarantine due to exposure to or
                illness from the virus, or stay
                home to take care of family
                members--all of which further
                strains staffing resources.
------------------------------------------------------------------------
Personal       According to our reviews of data      Challenge has
 Protective     from the CDC and interviews with      generally shown
 Equipment      advocacy organization and national    improvement
 (PPE)          association officials from July
                2020 to January 2021, shortages of
                PPE in nursing homes have improved
                since the beginning of the COVID-19
                pandemic but remain an issue:
 
                CDC data show that, as recently as
                December 2020, about 10 percent of
                nursing homes did not have a one-
                week supply of at least one of the
                following: N95 respirators,
                surgical masks, gloves, eye
                protection, or gowns (a decrease
                from about 22 percent of nursing
                homes in July 2020).
 
                In interviews with advocacy
                organizations and national
                association officials from July
                2020 to January 2021, we heard
                that, while challenges maintaining
                PPE supplies in reserve is an
                ongoing concern, supply shortages
                have become less severe over time.
------------------------------------------------------------------------
Testing        According to our reviews of CDC data  Challenge has
                and interviews with a researcher      generally shown
                and with nursing home association     improvement
                officials in November 2020 and
                January 2021, nursing homes'
                ability to use testing to identify
                infected residents and staff
                through testing protocols has
                improved over the course of the
                pandemic, but at a high cost to
                nursing homes:
 
                Nursing homes have reported to CDC
                improved testing capacity.
                Specifically, the number of nursing
                homes testing for COVID-19 in both
                staff and residents has increased
                by 48 percentage points--from 35 to
                83 percent--between August 16,
                2020, and November 22, 2020, the
                last week complete data for overall
                testing were available.
 
                Although data reported in December
                2020 by nursing homes found that
                less than 2 percent of nursing
                homes would be unable to test all
                staff or residents within the week
                if needed, nursing home association
                officials note that the high cost
                of continuous testing is not
                sustainable indefinitely.
------------------------------------------------------------------------
Vaccinations   According to our reviews of a CDC     Emerging challenge
                analysis of vaccination data and
                interviews with nursing home and
                State and local government
                officials, nursing homes face some
                emerging challenges related to
                vaccinations:
 
                A February 2021 CDC study
                estimated low rates of vaccine
                uptake among nursing home staff (38
                percent) compared to nursing home
                residents (78 percent)
                participating in the Pharmacy
                Partnership for Long-Term Care
                Program.b
 
                In interviews with nursing home
                and State and local government
                association officials since the
                vaccines were first administered in
                December 2020, we heard about
                reluctance among some nursing home
                staff to receive the COVID-19
                vaccine, in addition to hearing
                about uncertainty around certain
                aspects of vaccination distribution
                and requirements earlier in the
                year.
------------------------------------------------------------------------
Source: GAO review of CDC data and interviews. | GAO-21-402T
a According to CDC's data documentation, other support staff may include
  certified nursing assistants, medication aides, and medication
  technicians as reported to CDC by the provider.
b R. Gharpure, et al., ``Early COVID-19 First-Dose Vaccination Coverage
  Among Residents and Staff Members of Skilled Nursing Facilities
  Participating in the Pharmacy Partnership for Long-Term Care Program--
  United States, December 2020-January 2021,'' Centers for Disease
  Control and Prevention Morbidity and Mortality Weekly Report, vol. 70,
  no. 5 (2021): 178-182.

   hhs has taken steps in response to covid-19, but several relevant 
             gao recommendations have not been implemented
    Our prior CARES Act reports have described how HHS, primarily 
through CMS and CDC, has taken a series of actions to address COVID-19 
in nursing homes, such as providing guidance to nursing homes on 
infection control practices and issuing waivers and regulatory 
flexibilities.\9\ Examples of other actions include:
---------------------------------------------------------------------------
    \9\ For example, in March 2020 CMS waived the requirement that a 
nursing home not employ nurse aides for more than 4 months unless they 
meet certain training and certification requirements. This was done to 
address potential staffing shortages in nursing homes due to the COVID-
19 pandemic.

      Temporarily suspending State survey agencies' standard surveys 
and many complaint investigations, instead shifting to targeted 
infection prevention and control surveys and high-priority complaint 
investigations.\10\
---------------------------------------------------------------------------
    \10\ On June 1st, CMS issued survey re-prioritization guidance as 
part of its nursing home reopening strategy. Specifically, once a State 
enters phase 3--a threshold based on factors including case status in 
the community and the nursing home, as well as access to testing, PPE, 
and adequate staffing--state survey agencies were authorized to expand 
beyond conducting targeted infection control surveys and high-priority 
complaint investigations to include lower-priority complaint 
investigations. See Centers for Medicare and Medicaid Services, 
``COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement 
for Infection Control Deficiencies, and Quality Improvement Activities 
in Nursing Homes,'' QSO-20-31-ALL (Baltimore, MD.: June 1, 2020). On 
August 17, CMS revised this guidance to authorize traditional, 
comprehensive, standard surveys and lower-priority complaint 
investigations as soon as State survey agencies have the resources, 
such as staff and PPE. See Centers for Medicare and Medicaid Services, 
``Enforcement Cases Held During the Prioritization Period and Revised 
Survey Prioritization,'' QSO-20-35-ALL (Baltimore, MD.: August 17, 
2020).

      Creating a new reporting requirement for nursing homes to report 
weekly COVID-19 cases and deaths for residents and staff as of May 8, 
---------------------------------------------------------------------------
2020.

      Distributing antigen diagnostic tests and associated point-of-
care testing instruments to nursing homes.

      Distributing billions of dollars in payments from the Provider 
Relief Fund, established with funds provided under the CARES Act and 
other COVID-19 relief laws, as direct payments to assist nursing homes 
with responding to COVID-19.\11\
---------------------------------------------------------------------------
    \11\ As of January 15, 2021, $5 billion in Provider Relief Funds 
had been allocated for nursing homes and $4.764 billion had been 
disbursed.

      Convening the Coronavirus Commission on Safety and Quality in 
Nursing Homes (the Nursing Home Commission) in June 2020, which was 
tasked with assessing the response to the COVID-19 pandemic in nursing 
---------------------------------------------------------------------------
homes and made recommendations for additional actions CMS could take.

      Establishing the Pharmacy Partnership for Long-Term Care Program 
in October 2020, an agreement with CVS, Walgreens, and Managed Health 
Care Associates Inc. to provide and administer COVID-19 vaccines to 
residents of long-term care facilities, including nursing homes.

      Directing nursing homes to expand resident visitation beginning 
in March 2021, after previously restricting visitors and non-essential 
health care personnel in nursing homes, except in certain compassionate 
care situations, to reduce the transmission of COVID-19.\12\
---------------------------------------------------------------------------
    \12\ CMS restricted visitors and non-essential health care 
personnel in nursing homes from March through September 2020. In 
September 2020, CMS issued guidance that allowed for nursing homes to 
resume visitations depending on certain factors.

    However, HHS has not implemented several of our recommendations 
that could help the agency address some of the challenges nursing homes 
have faced and fill important voids in the Federal Government's 
understanding of, and transparency around, data on COVID-19 in nursing 
homes. (See app. I for a description of related GAO reports and the 
---------------------------------------------------------------------------
status of their recommendations.)

      HHS has not implemented our recommendation related to the 
Nursing Home Commission report. CMS released the Nursing Home 
Commission's final report in September 2020, which includes 27 
recommendations organized under 10 themes--such as Testing and 
Screening, Equipment and PPE, Workforce (staffing), and Visitation--
that are paired with over 100 specific action steps for CMS.\13\ CMS 
released a response to the report broadly outlining the actions the 
agency has taken to date as part of its response to the COVID-19 
pandemic, but the agency did not provide an implementation plan that 
would allow it to track and report progress toward the Commission's 
recommendations.
---------------------------------------------------------------------------
    \13\ MITRE, Coronavirus Commission on Safety and Quality in Nursing 
Homes: Commission Final Report, PRS Release Number 20-2382, September 
2020.

       We recommended in November 2020 that the Administrator of CMS 
quickly develop a plan that further details how the agency intends to 
respond to and implement, as appropriate, the 27 recommendations in the 
final report of the Coronavirus Commission on Safety and Quality in 
Nursing Homes. HHS neither agreed nor disagreed with our 
recommendation; instead, it highlighted actions CMS has taken related 
to Commission recommendations and indicated that it would refer to and 
act upon the Nursing Home Commission's recommendations as appropriate. 
---------------------------------------------------------------------------
CMS reiterated this position in February 2021.

      HHS has not implemented our recommendation to fill COVID-19 data 
voids. HHS, through CMS, implemented a COVID-19 reporting requirement 
for nursing homes effective May 8, 2020 (noted briefly above).\14\ CMS 
made the reporting of the data prior to May 8, 2020, optional. As a 
result, CMS's data do not capture the early months of the pandemic.\15\
---------------------------------------------------------------------------
    \14\ 85 Fed. Reg. 27,550, 27,627 (May 8, 2020) (to be codified at 
42 CFR Sec. 483.80(g)). CMS is responsible for ensuring that nursing 
homes meet Federal quality standards to participate in the Medicare and 
Medicaid programs.
    \15\ Nursing homes are required to self-report data regarding 
COVID-19 cases and deaths among residents and staff, PPE supplies, and 
staffing shortages, among other things, at least weekly through CDC's 
National Healthcare Safety Network.

       We recommended in September 2020 that the Secretary of HHS, in 
consultation with CMS and CDC, develop a strategy to capture more 
complete data on confirmed COVID-19 cases and deaths in nursing homes 
retroactively back to January 1, 2020, and clarify the extent to which 
nursing homes had reported data before May 8, 2020.\16\ Although HHS 
partially agreed with this recommendation and indicated that it 
continues to consider how to implement this recommendation, the agency 
had taken no specific actions, as of February 2021.
---------------------------------------------------------------------------
    \16\ Also in September 2020, GAO identified gaps in COVID-19 data 
for racial and ethnic minority groups, and, among other things, 
recommended that CDC take steps to help ensure its ability to 
comprehensively assess the long-term health outcomes of persons with 
COVID-19, including by race and ethnicity. HHS agreed with the 
recommendation and as of February 2021, CDC is reviewing the quality of 
the demographic data and assessing potential opportunities to enhance 
the collection of race and ethnicity data.

    We maintain the importance of our recommendations. Specifically, we 
maintain that developing a plan for whether CMS will proceed with the 
Nursing Home Commission's recommendations and, if so, how it will do so 
would improve the agency's ability to systematically consider the 
Nursing Home Commission's recommendations going forward. We also 
maintain that collecting data on COVID-19 cases and deaths from nursing 
homes retroactively would better inform the government's continued 
response to, and recovery from, the COVID-19 pandemic, and we maintain 
that HHS could ease the burden by incorporating data previously 
---------------------------------------------------------------------------
reported to CDC or to State or local public health offices.

    We also have recommendations from work completed prior to the 
pandemic that have yet to be fully implemented by CMS. Implementation 
of these recommendations could improve HHS's oversight of nursing homes 
both generally and during a pandemic. For example, in our 2019 report 
on abuse in nursing homes, we made six recommendations, including 
recommending that CMS require State survey agencies to immediately 
notify law enforcement of any reasonable suspicion of a crime against a 
resident, and that CMS provide more guidance to State survey agencies 
on the information nursing homes should include on facility-reported 
incidents. CMS agreed with our recommendations.\17\ These 
recommendations have relevance prior to, during, and after the COVID-19 
pandemic, because with reduced visitors or ombudsmen presence in 
nursing homes, and with the decrease or elimination of surveyor 
presence, there may be a higher risk of residents being abused and of 
that abuse going unreported.\18\ This risk is higher than it needs to 
be because CMS has not yet implemented our relevant recommendations.
---------------------------------------------------------------------------
    \17\ See GAO, Nursing Homes: Improved Oversight Needed to Better 
Protect Residents From Abuse, GAO-19-433 (Washington, DC: June 13, 
2019).
    \18\ State surveyors evaluate nursing homes' compliance with 
Federal quality standards.

    In addition to monitoring HHS's implementation of past 
recommendations, we have ongoing work examining COVID-19 outbreaks in 
nursing homes, as well as CMS's oversight of infection prevention and 
control protocols and the adequacy of emergency preparedness standards 
---------------------------------------------------------------------------
for emerging infectious diseases in nursing homes.

    In summary, the COVID-19 pandemic has underscored the importance of 
issues we have previously raised about nursing home quality and 
oversight while pointing to new vulnerabilities unique to the pandemic. 
Effective Federal oversight and support for nursing homes are 
especially critical during times of widespread disease outbreak, as the 
pandemic has demonstrated. As nursing homes are prioritized for 
vaccination, there is hope that COVID-19 cases and deaths in these 
homes will continue to decline. Going forward, our work on COVID-19 in 
nursing homes remains important for informing future pandemic 
responses, as well as for addressing longer-standing challenges that 
have put residents' health and safety at risk, as indicated by our 
prior recommendations.

    Chairman Wyden, Ranking Member Crapo, and members of the committee, 
this concludes my prepared statement. I would be pleased to respond to 
any questions that you may have at this time.
            appendix i: description of selected gao reports 
                 on nursing homes with recommendations
    The following table summarizes the status of relevant 
recommendations from GAO's prior reports on nursing home oversight with 
the status as of the most recent detailed update. According to the 
Centers for Medicare and Medicaid Services (CMS), as of March 2021, 
there are no additional updates on the status of these recommendations, 
as the agency's focus has been on responding to the pandemic.


   Table 1: Description of Selected GAO Reports on Nursing Homes With
            Recommendations, April 2011 Through November 2020
------------------------------------------------------------------------
    Date              Title              Summary of recommendations
------------------------------------------------------------------------
November      COVID-19: Urgent      GAO made one recommendation related
 2020          Actions Needed to     to nursing homes that the Centers
               Better Ensure an      for Medicare and Medicaid Services
               Effective Federal     (CMS) should quickly develop a plan
               Response              that further details how the agency
              (GAO-21-191)           intends to respond to and
                                     implement, as appropriate, the 27
                                     recommendations in the final report
                                     of the Coronavirus Commission on
                                     Safety and Quality in Nursing
                                     Homes, which CMS released on
                                     September 16, 2020. The Department
                                     of Health and Human Services (HHS)
                                     neither agreed nor disagreed with
                                     our recommendation and, as of
                                     February 2021, HHS/CMS had not
                                     implemented this recommendation.
------------------------------------------------------------------------
September     COVID-19: Federal     GAO made one recommendation related
 2020          Efforts Could Be      to nursing homes that HHS, in
               Strengthened by       consultation with CMS and the
               Timely and            Centers for Disease Control and
               Concerted Actions     Prevention (CDC), develop a
              (GAO-20-701)           strategy to capture more complete
                                     data on confirmed COVID-19 cases
                                     and deaths in nursing homes
                                     retroactively to January 1, 2020,
                                     in order to address gaps in the new
                                     reporting requirements on COVID-19
                                     cases and deaths in nursing homes.
                                     HHS partially agreed with this
                                     recommendation and, as of February
                                     2021, HHS had not implemented this
                                     recommendation.
------------------------------------------------------------------------
June 2019     Nursing Homes:        GAO made six recommendations,
               Improved Oversight    including that CMS require State
               Needed to Better      survey agencies to immediately
               Protect Residents     notify law enforcement of any
               from Abuse            reasonable suspicion of a crime
              (GAO-19-433)           against a resident, and that CMS
                                     provide more guidance to State
                                     survey agencies on the information
                                     nursing homes should include on
                                     facility-reported incidents. HHS
                                     agreed with the recommendations
                                     and, as of February 2020, HHS had
                                     not implemented these
                                     recommendations.
------------------------------------------------------------------------
April 2019    Management Report:    GAO made three recommendations,
               CMS Needs to          including that CMS ensure all State
               Address Gaps in       survey agencies are meeting Federal
               Federal Oversight     requirements for investigating
               of Nursing Home       alleged abuse, and that the results
               Abuse                 are shared with CMS. HHS agreed
               Investigations That   with the recommendations and, as of
               Persisted in Oregon   November 2019, HHS had implemented
               for at Least 15       one of the three recommendations.
               Years
              (GAO-19-313R)
------------------------------------------------------------------------
November      Nursing Homes:        GAO made four recommendations,
 2016          Consumers Could       including that CMS should add
               Benefit from          information to the Five-Star System
               Improvements to the   that allows consumers to compare
               Nursing Home          nursing homes nationally. HHS
               Compare Website and   agreed with three of the four
               Five-Star Quality     recommendations and, as of July
               Rating System         2019, HHS had implemented three of
              (GAO-17-61)            the four recommendations.
------------------------------------------------------------------------
October 2015  Nursing Home          GAO made three recommendations,
               Quality: CMS Should   including that CMS implement a
               Continue to Improve   clear plan for ongoing auditing of
               Data and Oversight    self-reported data and establish a
              (GAO-16-33)            process for monitoring oversight
                                     modifications to better assess
                                     their effects. HHS agreed with
                                     GAO's recommendations. As of 2020,
                                     HHS had implemented these three
                                     recommendations.
------------------------------------------------------------------------
April 2011    Nursing Homes: More   GAO made seven recommendations aimed
               Reliable Data and     at ensuring CMS's complaints
               Consistent Guidance   database is reliable, strengthening
               Would Improve CMS     CMS's assessment of State survey
               Oversight of State    agencies' performance in managing
               Complaint             complaints, and increasing
               Investigations        accountability for managing the
              (GAO-11-280)           complaints process. HHS generally
                                     agreed with our recommendations. As
                                     of October 2019, HHS had
                                     implemented two of these seven
                                     recommendations and indicated it
                                     would not be taking action on a
                                     third (GAO closed this as not
                                     implemented).
------------------------------------------------------------------------
Source: GAO. | GAO-21-402T
Note: The hyperlinks to these reports provide additional details about
  the recommendations and their statuses.

                    appendix ii: related gao reports
CARES Act Reports
COVID-19: Critical Vaccine Distribution, Supply Chain, Program 
Integrity, and Other Challenges Require Focused Federal Attention. GAO-
21-265. Washington, DC: January 28, 2021.

COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal 
Response. GAO-21-191. Washington, DC: November 30, 2020.

COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted 
Actions. GAO-20-701. Washington, DC: September 21, 2020.

COVID-19: Opportunities to Improve Federal Response and Recovery 
Efforts. GAO-20-625. Washington, DC: June 25, 2020.
Other GAO Reports
Infection Control Deficiencies Were Widespread and Persistent in 
Nursing Homes Prior to COVID-19 Pandemic. GAO-20-576R. Washington, DC: 
May 20, 2020.

Elder Abuse: Federal Requirements for Oversight in Nursing Homes and 
Assisted Living Facilities Differ. GAO-19-599. Washington, DC: August 
19, 2019.

Nursing Homes: Improved Oversight Needed to Better Protect Residents 
from Abuse. GAO-19-433. Washington, DC: June 13, 2019.

Management Report: CMS Needs to Address Gaps in Federal Oversight of 
Nursing Home Abuse Investigations That Persisted in Oregon for at Least 
15 Years. GAO-19-313R. Washington, DC: April 15, 2019.

Nursing Homes: Consumers Could Benefit from Improvements to the Nursing 
Home Compare Website and Five-Star Quality Rating System. GAO-17-61. 
Washington, DC: November 18, 2016.

Nursing Home Quality: CMS Should Continue to Improve Data and 
Oversight. GAO-16-33. Washington, DC: October 30, 2015.

Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use Among Older 
Adults in Nursing Homes, but Should Expand Efforts to Other Settings. 
GAO-15-211. Washington, DC: January 30, 2015.

Nursing Homes: More Reliable Data and Consistent Guidance Would Improve 
CMS Oversight of State Complaint Investigations. GAO-11-280. 
Washington, DC: April 7, 2011.

                                 ______
                                 
          Questions Submitted for the Record to John E. Dicken
                 Questions Submitted by Hon. Ron Wyden
    Question. What changes do you recommend to the Five-Star system so 
it will better reflect patients' outcomes of care and inform residents 
and loved ones about the quality and safety of nursing homes?

    Answer. We last reported on the Five-Star Quality Rating System 
(Five-Star System) in November 2016 (see GAO-17-61). We made four 
recommendations in that report, three of which have been implemented by 
the Centers for Medicare and Medicaid Services (CMS) and one of which 
remains unimplemented.

    With regard to the unimplemented recommendation, we recommended 
that, to help improve the Five-Star System's ability to enable 
consumers to understand nursing home quality and make distinctions 
between high- and low-performing homes, the Administrator of CMS should 
add information to the Five-Star System that allows consumers to 
compare nursing homes nationally. The Department of Health and Human 
Services (HHS) did not concur with this recommendation. In July 2019, 
CMS officials told us they do not plan to implement this 
recommendation, and as of March 2021 CMS had not informed us of steps 
taken to address the recommendation. However, we maintain that adding 
national comparison information is important, especially for those 
consumers who live near State borders or have multi-State options.

    We also recommended in that report that CMS evaluate the 
feasibility of adding consumer satisfaction information to the Five-
Star System. HHS concurred with this recommendation and provided us 
with such a study dated October 2017, leading us to close the 
recommendation as implemented. However, the study described 
``widespread consensus that measuring satisfaction of nursing home 
residents and families is crucial to understanding resident experience 
and to informing consumers on choosing a nursing home.'' This suggests 
that CMS could better inform residents and their loved ones about the 
quality and safety of nursing homes by taking the next step of adding 
consumer satisfaction information to the Five-Star System.

    As GAO continues to evaluate the federal response to COVID-19 in 
nursing homes and the effects of the pandemic on the safety and welfare 
of nursing home residents, we will also monitor challenges the pandemic 
will pose for CMS's Five-Star System going forward. For example, 
nursing home inspection results are one key element of the Five-Star 
System's ratings, but many standard inspections have not occurred or 
have been delayed during this national emergency, consistent with CMS's 
guidelines. Thus, the information consumers receive from the Five-Star 
System will be a less timely and accurate representation of care 
provided during the pandemic.

    Question. The involvement of private equity in the nursing home 
industry has been of interest to the Finance Committee for more than a 
decade, and the role of private equity and for profit ownership in the 
nursing home industry was raised in testimony and questions at the 
hearing. The Government Accountability Office (GAO) considered this 
issue in a 2010 report, ``Nursing Homes: Complexity of Private 
Investment Purchases Demonstrates Need for CMS to Improve the Usability 
and Completeness of Ownership Data.'' Please provide an update on the 
status of the recommendations made in this report.

    Answer. The 11 recommendations from that report, GAO-10-710, are 
closed. Five were closed as implemented, and six were closed as not 
implemented. The recommendations not implemented are summarized in the 
following paragraphs, but full details are available in the report and 
on the GAO website.

    Three of the recommendations not implemented relate to the Patient 
Protection and Affordable Care Act (PPACA), which expanded the 
ownership and control reporting requirements for Medicare and Medicaid 
nursing homes. At the time we reported, these PPACA requirements had 
not yet been implemented, and we recommended that HHS consider 
requiring certain types of reporting as it developed the regulations to 
implement these requirements. For each of these recommendations, CMS 
told GAO that it had taken steps to obtain the recommended information 
by making changes to its provider enrollment application form. However, 
in each case GAO assessed that the changes did not specifically or 
sufficiently address the information targeted by our recommendations. 
Because CMS had not indicated any plans to take further actions at the 
time these recommendations were closed, GAO considered them to be 
closed and not implemented.

    The other three recommendations not implemented related to 
information HHS should require nursing homes to report or to actions 
HHS should take to ensure the usability, accuracy, and completeness of 
nursing home ownership information. In the case of our recommending an 
additional reporting requirement, CMS told GAO that, upon further 
review, it had determined that taking action would represent an undue 
burden on providers, given the existing functionality of its provider 
enrollment system, and that the agency considered the matter closed. In 
the other two cases, CMS told GAO about actions it had taken related to 
the recommendations and said that the agency had no further updates and 
considered the matters closed.

    GAO currently has ongoing work related to the quality of nursing 
homes with chain ownership, including private equity owners, which 
should provide more up-to-date information on this topic.

    Question. During the hearing, several Senators and witnesses raised 
the importance of the Federal Government collecting and publishing 
information from individual nursing homes that show the rate of 
vaccinations for residents and staff. Since that time, a bipartisan 
group of senators have sent a letter to the U.S. Department of Health 
and Human Services calling on it to take steps to begin this data 
collection. Has GAO issued any recommendations in relation to this 
issue?

    Answer. The Federal Government's collection and reporting of 
nursing home vaccination data is important for providing insight into 
nursing home quality of care and protecting the vulnerable nursing home 
population. We made two recommendations related to this issue in our 
March 2021 CARES Act report (see GAO-21-387).

    First, we recommended that the Secretary of HHS should ensure that 
the Director of the CDC collects data specific to the COVID-19 
vaccination rates in nursing homes and makes these data publicly 
available to better ensure transparency and that the necessary 
information is available to improve ongoing and future vaccination 
efforts for nursing home residents and staff. HHS neither agreed nor 
disagreed with this recommendation.

    In response to our recommendation, HHS said it is working towards 
better data transparency and noted that nursing homes have an 
opportunity to voluntarily report data through the National Healthcare 
Safety Network (NHSN) tracking system. However, according to CDC, as of 
February 17, 2021, around 14 percent of nursing homes are voluntarily 
reporting staff vaccination data through NHSN and around 18 percent are 
voluntarily reporting resident vaccination data. We maintain that more 
complete data on COVID-19 vaccinations in nursing homes will be 
important for CMS's ongoing efforts to monitor nursing home quality and 
that making these data transparent through public reporting provides 
consumers with insight into how well nursing homes are caring for their 
residents.

    Second, we recommended that the Secretary of HHS should ensure that 
the Administrator of CMS, in consultation with CDC, requires nursing 
homes to offer COVID-19 vaccinations to residents and staff and design 
and implement associated quality measures. HHS neither agreed nor 
disagreed with this recommendation.

    In response to our recommendation, HHS indicated that CMS is 
``actively evaluating'' whether changes need to be made to its 
infection control requirements regarding the COVID-19 vaccine and that 
CMS and CDC ``have made progress in developing quality measures related 
to COVID-19 vaccination.'' We note that CMS already requires nursing 
homes to offer influenza and pneumococcal vaccinations to nursing home 
residents; given the significant threat COVID-19 poses to nursing home 
residents, with a mortality rate far exceeding that of influenza, we 
maintain the importance of this recommendation for protecting the 
vulnerable nursing home population.

    On April 8, 2021, CMS published a proposed rule that, among other 
things, proposes the adoption of a ``COVID-19 Vaccination Coverage 
among Healthcare Personnel'' quality measure. This would require 
Skilled Nursing Facilities (SNF) to report on COVID-19 vaccination of 
staff. Under the proposal, SNFs would begin reporting vaccination data 
through CDC's NHSN beginning October 1, 2021, and the quality measure 
would be adopted beginning in fiscal year 2023. We will continue to 
monitor CMS's actions responding to these two recommendations.

    Question. The South African and Brazilian variants continue to 
circulate in the United States. What are issues Congress should 
consider in regards to the danger that these and other COVID-19 
variants may pose to nursing homes, particularly residents who have 
been most vulnerable to the disease?

    Answer. As we noted in our March 2021 CARES Act report (see GAO-21-
387), the emergence of new COVID-19 variants underscores the need to 
remain vigilant in efforts to contain the spread of the virus. For 
example, one expert we interviewed noted that different variants could 
increase the number of COVID-19 cases and deaths and reduce health care 
systems' ability to care for patients. Because nursing home residents 
are at high risk for COVID-19 infection and death, due to the virus's 
high mortality rate among elderly adults and those with underlying 
conditions, continued vigilance is especially important for nursing 
homes.

    As we reported in the same March 2021 report, several experts told 
us that it is important for the federal government to help the public 
and stakeholders understand how to use its COVID-19 data, and one 
expert specifically highlighted the importance of doing so for data on 
COVID-19 variants. While CDC already makes data available on case 
numbers for COVID-19 variants, this expert told us that it is also 
important for the federal government to explain how to interpret these 
numbers and describe how stakeholders, including State and local public 
health officials, could use these data to inform their efforts to 
respond to the pandemic. This could include how data could be used to 
inform response efforts in nursing homes.

    Additionally, collecting more complete data on COVID-19 
vaccinations in nursing homes, as we recommended in our March 2021 
CARES Act report (see previous response), could help with understanding 
whether vaccinated residents may be vulnerable to infection by COVID-19 
variants. Similarly, demographic data, such as race and ethnicity data, 
for COVID-19 in nursing homes could help with understanding whether 
COVID-19 variants may have a disproportionate effect on a particular 
group. In our September CARES Act report (see GAO-20-701), we made 
three recommendations related to the collection of demographic data for 
COVID-19, including data on race and ethnicity; these recommendations 
remain open.

    Question. Is additional surveillance necessary to detect the spread 
of viral variants? What types of surveillance, if any, should be 
implemented in regards to the nursing home industry specifically?

    Answer. Surveillance is important for understanding the 
transmission of the virus, including variants. More complete data on 
COVID-19 in nursing homes, including data on COVID-19 vaccinations and 
demographic data, may help with understanding the impact of COVID-19 
variants on nursing home residents. CMS and CDC could begin to gather 
more complete data on COVID-19 in nursing homes by implementing our 
recommendations.

    Question. In the event that additional vaccinations and/or booster 
shots are needed to protect against variants, what lessons can be drawn 
from the experience of the CVS Walgreen Long-Term Care Partnership?

    Answer. While we have not done a full evaluation of the Pharmacy 
Partnership for Long-Term Care Program, we noted in our March 2021 
CARES Act report (see GAO-21-387) that a key challenge was the 
decentralization of the partnership program. Originally designed to be 
a federal program, each State was ultimately responsible for activating 
the partnership and allocating doses to the partnership. According to 
State and nursing home association officials, this resulted in more 
than 50 different plans for implementation, which caused confusion 
among jurisdictions' health departments, nursing homes, and pharmacy 
partners and hampered communication and vaccine education efforts. The 
officials said a more centralized distribution model may have created a 
more efficient approach to vaccinating the nursing home population.

    Question. The GAO has issued numerous recommendations related to 
nursing homes over the years. Please provide a list of all outstanding 
recommendations that relate to the Centers for Medicare and Medicaid 
Services and remain open.

    Answer. The following recommendations related to nursing homes and 
CMS remain open. We maintain that implementing these recommendations 
could improve HHS's oversight of nursing homes both generally and 
during a pandemic.

     1.  The Secretary of HHS should ensure that the Administrator of 
CMS, in consultation with CDC, requires nursing homes to offer COVID-19 
vaccinations to residents and staff and design and implement associated 
quality measures.

        Source: GAO-21-387, published March 31, 2021.

     2.  The Administrator of CMS should quickly develop a plan that 
further details how the agency intends to respond to and implement, as 
appropriate, the 27 recommendations in the final report of the 
Coronavirus Commission on Safety and Quality in Nursing Homes, which 
CMS released on September 16, 2020. Such a plan should include 
milestones that allow the agency to track and report on the status of 
each recommendation; identify actions taken and planned, including 
areas where the CMS determined not to take action; and identify areas 
where the agency could coordinate with other federal and nonfederal 
entities.

        Source: GAO-21-191, published November 30, 2020.

     3.  The Secretary of HHS, in consultation with CMS and CDC, should 
develop a strategy to capture more complete data on confirmed COVID-19 
cases and deaths in nursing homes retroactively back to January 1, 
2020, and to clarify the extent to which nursing homes have reported 
data before May 8, 2020. To the extent feasible, this strategy to 
capture more complete data should incorporate information nursing homes 
previously reported to CDC or to State or local public health offices.

        Source: GAO-20-701, published September 21, 2020.

     4.  The administrator of CMS should require that abuse and 
perpetrator type be submitted by State survey agencies in CMS's 
databases for deficiency, complaint, and facility reported incident 
data, and that CMS systematically assess trends in these data.

        Source: GAO-19-433, published June 13, 2019.

     5.  The administrator of CMS should require State survey agencies 
to immediately refer complaints and surveys to law enforcement (and, 
when applicable, to Medicaid Fraud Control Units) if they have a 
reasonable suspicion that a crime against a resident has occurred when 
the complaint is received.

        Source: GAO-19-433, published June 13, 2019.

     6.  The administrator of CMS should develop and disseminate 
guidance--including a standardized form--to all State survey agencies 
on the information nursing homes and covered individuals should include 
on facility-reported incidents.

        Source: GAO-19-433, published June 13, 2019.

     7.  The administrator of CMS should conduct oversight of State 
survey agencies to ensure referrals of complaints, surveys, and 
substantiated incidents with reasonable suspicion of a crime are 
referred to law enforcement (and, when applicable, to Medicaid Fraud 
Control Units) in a timely fashion.

        Source: GAO-19-433, published June 13, 2019.

     8.  The administrator of CMS should develop guidance for State 
survey agencies clarifying that allegations verified by evidence should 
be substantiated and reported to law enforcement and State registries 
in cases where citing a federal deficiency may not be appropriate.

        Source: GAO-19-433, published June 13, 2019.

     9.  The administrator of CMS should provide guidance on what 
information should be contained in the referral of abuse allegations to 
law enforcement.

        Source: GAO-19-433, published June 13, 2019.

    10.  CMS should evaluate State survey agency processes in all 
States to ensure all State survey agencies are meeting federal 
requirements that State survey agencies are responsible for 
investigating complaints and facility-reported incidents alleging abuse 
in nursing homes, and that the results of those investigations are 
being shared with CMS.

        Source: GAO-19-313R, published April 15, 2019.

    11.  CMS should identify options for capturing information from 
Oregon's Adult Protective Services investigations of complaints and 
facility-reported incidents of abuse and incorporate this information 
into oversight of Oregon nursing homes.

        Source: GAO-19-313R, published April 15, 2019.

    12.  To help improve the Five-Star System's ability to enable 
consumers to understand nursing home quality and make distinctions 
between high- and low- performing homes, the Administrator of CMS 
should add information to the Five-Star System that allows consumers to 
compare nursing homes nationally.

        Source: GAO-17-61, published November 18, 2016.

    13.  To improve the accessibility and reliability of SNF 
expenditure data, the Acting Administrator of CMS should take steps to 
improve the accessibility of SNF expenditure data, making it easier for 
public stakeholders to locate and use the data.

        Source: GAO-16-700, published September 7, 2016.

    14.  To improve the accessibility and reliability of SNF 
expenditure data, the Acting Administrator of CMS should take steps to 
ensure the accuracy and completeness of SNF expenditure data.

        Source: GAO-16-700, published September 7, 2016.

    15.  To improve consumers' access to relevant and understandable 
information on the cost and quality of health care services, the 
Secretary of HHS should direct the Administrator of CMS to include in 
the CMS Compare websites, to the extent feasible, estimated out-of-
pocket costs for Medicare beneficiaries for common treatments that can 
be planned in advance.

        Source: GAO-15-11, published October 20, 2014.

    16.  To improve consumers' access to relevant and understandable 
information on the cost and quality of health care services, the 
Secretary of HHS should direct the Administrator of CMS to organize 
cost and quality information in the CMS Compare websites to facilitate 
consumer identification of the highest-performing providers, such as by 
listing providers in order based on their performance.

        Source: GAO-15-11, published October 20, 2014.

    17.  To improve consumers' access to relevant and understandable 
information on the cost and quality of health-care services, the 
Secretary of HHS should direct the Administrator of CMS to include in 
the CMS Compare websites the capability for consumers to customize the 
information presented, to better focus on information relevant to them.

        Source: GAO-15-11, published October 20, 2014.

    18.  To improve consumers' access to relevant and understandable 
information on the cost and quality of health-care services, the 
Secretary of HHS should direct the Administrator of CMS to develop 
specific procedures and performance metrics to ensure that CMS's 
efforts to promote the development and use of its own and others' 
transparency tools adequately address the needs of consumers.

        Source: GAO-15-11, published October 20, 2014.

    19.  To ensure that information entered into CMS's complaints 
database is reliable and consistent, the Administrator of CMS should 
identify issues with data quality and clarify guidance to States about 
how particular fields in the database should be interpreted, such as 
what it means to substantiate a complaint.

        Source: GAO-11-280, published April 7, 2011.

    20.  To strengthen CMS's assessment of State survey agencies' 
performance in the management of nursing home complaints , the 
Administrator of CMS should conduct additional monitoring of State 
performance using information from CMS's complaints database, such as 
additional timeliness measures.

        Source: GAO-11-280, published April 7, 2011.

    21.  To strengthen and increase accountability of State survey 
agencies' management of the nursing home complaints process, the 
Administrator of CMS should clarify guidance to the State survey 
agencies about the minimum information that should be conveyed to 
complainants at the close of an investigation.

        Source: GAO-11-280, published April 7, 2011.

    22.  To strengthen and increase accountability of State survey 
agencies' management of the nursing home complaints process, the 
Administrator of CMS should provide guidance encouraging State survey 
agencies to prioritize complaints at the level that is warranted, not 
above that level.

        Source: GAO-11-280, published April 7, 2011.

                                 ______
                                 
              Questions Submitted by Hon. Elizabeth Warren
    Question. Please provide a full list of all GAO recommendations 
related to CMS's Provider Enrollment, Chain, and Ownership System 
(PECOS) that the agency has yet to complete and identify which 
recommendations have not been implemented by CMS or other relevant 
regulators.

    Answer. GAO does not currently have any open recommendations 
targeted to CMS's Provider Enrollment, Chain, and Ownership System 
(PECOS). However, we have made recommendations targeted to PECOS in the 
past, several of which were closed as implemented (see, for example, 
GAO-15-448). At least one recommendation targeted to PECOS--from our 
2010 report on private investment in nursing homes, GAO-10-710--was 
closed as not implemented:

    1.  To improve the usability and accuracy of the ownership and 
control information collected and stored in PECOS, the Administrator of 
CMS should examine State systems to identify best practices for the 
collection and public dissemination of nursing home ownership and chain 
information, including ways in which States make the hierarchy among 
owners more apparent.

          In 2012, CMS told GAO that it had recently implemented an 
automated provider screening system and that it was continuing to have 
internal discussions and explore data sources that can provide nursing 
home information for that system. However, CMS said it had no further 
updates and that it considered the matter closed.

    Question. What recommendations, if any, does GAO have for the 
executive branch to improve its visibility into the ownership of 
private-equity-owned nursing homes?

    Answer. GAO does not have any open recommendations related to 
private-equity-owned nursing homes. However, GAO currently has ongoing 
work related to the quality of nursing homes with chain ownership, 
including private equity owners.

    Question. GAO has analyzed nursing homes through the lens of the 
COVID-19 pandemic and provided Congress with a series of 
recommendations. Are any of GAO's COVID-19-related recommendations 
specifically targeted at or relevant for for-profit facilities, 
including private-equity-owned facilities? Did the COVID-19 pandemic 
reveal any differences in the ability of for- and non-profit facilities 
to provide high-quality care to residents or to protect them from 
pandemics?

    Answer. None of the four COVID-19-related nursing homes 
recommendations from our CARES Act reporting are specifically targeted 
to for-profit facilities; however, each of the four recommendations is 
relevant to all nursing homes, which would include for-profit 
facilities (see Lankford question, later in this response, for a list 
of these recommendations).

    GAO currently has ongoing work looking at which nursing home 
characteristics, if any, affect the likelihood that a home experienced 
a COVID-19 outbreak. We are also aware of ongoing work from the HHS 
Office of Inspector General (OIG) that will describe the 
characteristics of the nursing homes that were hardest hit by the 
pandemic (OEI-02-20-00490).

    Additionally, although not specific to the COVID-19 pandemic, we 
have previously reported on the intersection of nursing home 
characteristics and nursing home quality:

          In May 2020, we reported that, over a 5-year period, while 
nursing homes owned by for-profit organizations comprised about 68 
percent of all surveyed nursing homes, they accounted for 72 percent of 
nursing homes that had infection prevention and control deficiencies 
cited in multiple years but only about 61 percent of nursing homes with 
no infection prevention and control deficiencies cited (see GAO-20-
576R).

          In 2015, we reported that the poorest performing nursing 
homes were more likely to be for-profit or large homes (greater than 
100 beds) compared to homes that performed well; this was consistent 
with a 2009 GAO analysis on the most poorly performing nursing homes 
(see GAO-16-33, GAO-09-689).

          In 2011, we reported that private investment and other for-
profit nursing homes had more total deficiencies than nonprofit homes, 
both before and after acquisition by private investment firms (see GAO-
11-571).

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. Through the years, nursing homes in my State have 
reported they have lost the ability to train their own CNAs. According 
to an article published in Health Affairs, this is because nursing 
homes with a civil monetary penalty greater than $10,000 lose the 
ability to conduct CNA training for 2 years. In rural communities, 
where the nursing home is often the sole source of training for CNAs, 
this creates a tremendous burden. Please comment on the impact losing 
the ability to train CNAs has on nursing homes.

    Answer. GAO does not currently have any ongoing work or open 
recommendations focused on CNA training, including in rural 
communities, but, if you would like, we would be happy to follow up 
with your staff to further discuss this issue.

    We note that the Coronavirus Commission on Safety and Quality in 
Nursing Homes--which we refer to as the Nursing Home Commission and 
which was appointed by CMS--reported that the COVID-19 pandemic has 
disrupted CNA training, ``leading to serious CNA workforce deficits.'' 
The Nursing Home Commission recommended that CMS catalyze interest in 
the CNA profession through diverse recruitment vehicles; issue guidance 
for on-the-job CNA training, testing, and certification; and create a 
national CNA registry.\1\
---------------------------------------------------------------------------
    \1\ MITRE, Coronavirus Commission on Safety and Quality in Nursing 
Homes: Commission Final Report, PRS Release Number 20-2382, September 
2020.

    In our November 2020 CARES Act report (see GAO-21-191), we 
recommended that the Administrator of CMS quickly develop a plan that 
further details how the agency intends to respond to and implement, as 
appropriate, the 27 recommendations in the final report of the Nursing 
Home Commission. As of February 2021, this recommendation had not been 
implemented. However, we maintain the importance of this 
recommendation, as developing a plan for whether CMS will proceed with 
the Nursing Home Commission 's recommendations--and, if so, how it will 
do so--would improve the agency's ability to systematically consider 
the recommendations going forward, to include the recommendation 
---------------------------------------------------------------------------
related to CNAs.

    Question. Can you provide suggestions on how to address this 
situation, especially in rural communities?

    Answer. See previous response.

    Question. Please discuss the impact of staffing turnover on the 
quality of care provided in nursing homes.

    Answer. GAO has ongoing related work examining the relationship 
between staffing levels and the rate of critical incidents at skilled 
nursing facilities prior to the pandemic. If you would like, we would 
be happy to follow up with your staff to further discuss this issue.

    Question. Specifically, do you believe turnover rates from nursing 
homes should be made more readily available for public review?

    Answer. GAO does not have any recommendations on this issue. 
However, we are aware that the HHS OIG recently made a related 
recommendation. In March 2021, HHS OIG reported that federal law 
requires CMS to provide data on staffing turnover and tenure on Care 
Compare, but that CMS has not yet done so. CMS told HHS OIG that the 
agency was delayed by the COVID-19 pandemic. HHS OIG recommended that 
CMS provide data to consumers on nurse staff turnover and tenure, as 
required by federal law.\2\
---------------------------------------------------------------------------
    \2\ Department of Health and Human Services, Office of Inspector 
General, CMS Use of Data on Nursing Home Staffing: Progress and 
Opportunities To Do More, OEI-04-18-00451 (Washington, DC: March 2021).

                                 ______
                                 
                 Questions Submitted by Hon. Todd Young
    Question. What are some lessons learned from the public health 
emergency in terms of the integration of technology in nursing homes-
both in helping residents visit virtually with loved ones and in 
accessing health care services?

    Answer. GAO currently has ongoing work that may address the use of 
technology in nursing homes for telehealth and other purposes.

    For example, as part of our ongoing work examining nursing home 
challenges associated with the COVID-19 pandemic, we have interviewed 
officials from three State long-term care ombudsman programs, some of 
whom have utilized or plan to utilize technology to connect with 
residents during the pandemic.

    Additionally, we have ongoing work examining the use of telehealth 
in Medicare and Medicaid. This includes HHS's use of statutory and 
regulatory flexibilities to temporarily waive or modify Medicare 
telehealth provisions in response to COVID-19, as well as how States 
have used telehealth in Medicaid to respond to the pandemic. While this 
work is focused on Medicare and Medicaid broadly, it is also relevant 
to nursing homes specifically, because these waivers permit telehealth 
visits in nursing homes.

    Finally, in our January CARES Act report (see GAO-21-265, Veterans 
Health Care enclosure), we discussed the Department of Veterans 
Affairs' (VA) use of telehealth. Again, while not specific to nursing 
homes, this work is relevant because VA provides or pays for nursing 
home care in various settings. Among other things, we reported that 
VA's Veterans Health Administration (VHA) has several ongoing efforts 
aimed at removing technology barriers to telehealth use among veterans; 
for example, VHA has directed facilities to establish programs to help 
veterans become familiar with telehealth technology.

    Question. How do you anticipate this type of technology continuing 
to be used beyond the pandemic?

    Answer. Our ongoing work on telehealth in Medicare and Medicaid, 
mentioned earlier, may address this question. For example, as part of 
our ongoing work examining HHS's Medicare telehealth waivers, we plan 
to examine the perspectives of beneficiaries, providers, and payers on 
Medicare telehealth services and on the idea of making some Medicare 
telehealth waivers permanent.

    Question. Based on your oversight of CMS's infection prevention 
protocols and emergency preparedness standards, what further steps 
should the Federal Government take to encourage proper antibiotic 
stewardship in nursing homes?

    Answer. Last year, we issued a report on additional federal actions 
needed to reduce the impact of antibiotic resistant bacteria broadly, 
not limited to nursing homes (see GAO-20-341). In that report, we 
credited federal agencies for actions already taken to encourage proper 
antibiotic stewardship in nursing homes. For example, we noted that CMS 
published requirements for nursing homes and skilled nursing facilities 
to establish antibiotic stewardship programs by December 4, 2017, which 
experts credited as being a powerful lever for promoting the 
appropriate use of antibiotics. We also noted that, since 2014, CDC has 
published a series of guidance documents called the Core Elements of 
Antibiotic Stewardship, which are tailored to nursing homes and other 
settings. However, challenges remain, such as in collecting antibiotic 
use data from nursing homes, which less commonly use electronic health 
record systems that would facilitate data access. The Federal 
Government could further encourage proper antibiotic stewardship 
generally, including in nursing homes, by implementing that report's 
eight recommendations, all of which remain open.

    Additionally, the Federal Government could address the one 
remaining open recommendation from our 2017 report on Food and Drug 
Administration (FDA) efforts to encourage the development of new 
antibiotics (see GAO-17-189). Specifically, we recommended that FDA 
develop and make available written guidance on the qualified infectious 
disease products (QIDP) designation that includes information about the 
process a drug sponsor must undertake to request the fast track 
designation, and about how the agency is applying the market 
exclusivity incentive. As of August 2020, FDA reported that it is 
working to finalize draft guidance issued in January 2018 that 
describes the QIDP designation.

                                 ______
                                 
                Questions Submitted by Hon. John Cornyn
    Question. GAO has noted the challenge of staff shortages that 
nursing homes have faced during the pandemic. Reports have noted the 
use of staffing agencies, shared staff with other providers, and the 
use of emergency waivers to hire nurse aides who have yet to complete 
their certification. What steps can be taken to provider greater 
flexibility to nursing homes to maintain necessary staff levels without 
negatively impacting resident care?

    Answer. We note that the Nursing Home Commission, which was 
appointed by CMS, made five recommendations (with more than 20 
associated action steps) related to stopgap measures to support the 
nursing home workforce.\3\ This included actions such as assessing 
federal relief funds for hazard pay options and updating interstate 
compact language addressing public health emergencies to support a 
surge-staffing pool in viral hotspots.
---------------------------------------------------------------------------
    \3\ MITRE, Commission Final Report, 41-47.

    In our November 2020 CARES Act report (see GAO-21-191), we 
recommended that the Administrator of CMS quickly develop a plan that 
further details how the agency intends to respond to and implement, as 
appropriate, the 27 recommendations in the final report of the Nursing 
Home Commission. As of February 2021, this recommendation had not been 
implemented. However, we maintain the importance of this 
recommendation, as developing a plan for whether CMS will proceed with 
the Nursing Home Commission's recommendations--and, if so, how it will 
do so--would improve the agency's ability to systematically consider 
the recommendations going forward, to include the recommendations 
---------------------------------------------------------------------------
related to stopgap measures to support the nursing home workforce.

    Additionally, GAO currently has ongoing work examining the use of 
contract staff in nursing homes.

    Along similar lines, HHS OIG reported in August 2020 that many 
nursing homes were not meeting required staffing levels even prior to 
the COVID-19 pandemic. In an analysis of 2018 data, HHS OIG found that 
14 percent of nursing homes reported 16 or more days where staffing was 
below required levels in 2018; another 40 percent reported between 1 
and 15 days where staffing was below required levels.\4\ HHS OIG noted 
that in April 2018, CMS announced it would automatically downgrade 
nursing homes' Staffing Star Ratings on Nursing Home Compare if they 
reported at least 7 total days with no reported registered nurse time 
during a quarter; according to OIG, 27 percent fewer nursing homes 
reported days with no registered nurse time following this 
announcement. However, OIG noted that there were still nursing homes 
falling short of meeting staffing requirements in ways not addressed by 
this penalty. HHS OIG recommended that CMS enhance its efforts to 
ensure nursing homes meet daily staffing requirements, such as by 
expanding the agency's use of Payroll Based Journal data to identify 
understaffed nursing homes and target them for further oversight.
---------------------------------------------------------------------------
    \4\ Department of Health and Human Services, Office of Inspector 
General, Some Nursing Homes' Reported Staffing Levels in 2018 Raise 
Concerns; Consumer Transparency Could Be Increased, OEI-04-18-00450 
(Washington, DC: August 2020).

    Question. GAO has also noted a reluctance in some nursing home 
staff to receive the COVID-19 vaccine. Are there specific 
---------------------------------------------------------------------------
recommendations to improve address this reluctance?

    Answer. In our March CARES Act report (see GAO-21-387), we shared 
that State and nursing home association officials had indicated that 
COVID-19 vaccine take-up rates among staff were lower than among 
residents. They attributed this to several factors, including 
underlying issues of government mistrust and myths spread on social 
media. However, because CDC does not have complete data on vaccines 
administered in nursing homes outside of the Pharmacy Partnership for 
Long-Term Care Program, and because CDC publicly reports vaccination 
information collected through that program only for all long-term care 
facilities (rather than nursing homes specifically), it is unclear how 
successful efforts have been to vaccinate nursing home staff.

    While GAO does not have specific recommendations to address nursing 
home staff reluctance to receive the COVID-19 vaccine, our March 
report's recommendations relating to nursing home COVID-19 vaccination 
data and associated quality measures could, if implemented, better 
ensure that the necessary information is available to improve ongoing 
and future vaccination efforts for nursing home staff. Additionally, 
they could help ensure that data on staff vaccination rates are 
available to help manage the risk of COVID-19 outbreaks in nursing 
homes and serve as an important source of information for consumers 
about quality of care. We note that, on April 8, 2021, CMS published a 
proposed rule related to these recommendations (see previous response 
to Wyden Q3) .

                                 ______
                                 
               Questions Submitted by Hon. James Lankford
    Question. What, in your opinion, does the nursing home industry 
need most to solve some of the problems that are consistently discussed 
surrounding nursing home facility underreporting, fraudulent reporting, 
and instances of abuse? Would you suggest different staff requirements 
and/or enhanced CMS oversight?

    Answer. GAO has several recommendations related to reporting (and 
underreporting) of abuse and COVID-19 data in nursing homes. By 
implementing these recommendations, Federal agencies could improve 
their oversight of nursing homes both generally and during a pandemic.

    We last reported on instances of abuse in nursing homes in November 
2019 (see testimony GAO-20-259T and related report GAO-19-433). We made 
six recommendations in GAO-19-433 (see Wyden Q5 earlier in our 
response, #4 through 9). CMS agreed with these recommendations, but 
they all remain open. The risk of residents being abused, and of that 
abuse going unreported, is higher than it needs to be because CMS has 
not yet implemented these recommendations.

    As we first reported in our September 2020 CARES Act report (see 
GAO-20-701), COVID-19 cases and deaths in nursing homes are likely 
underreported in CMS and CDC data because, among other reasons, CMS 
does not require nursing homes to report data prior to May 8, 2020. As 
a result, the data do not provide HHS with a complete picture of the 
extent of the pandemic and its effect on nursing homes. To address this 
issue, we recommended that the Secretary of HHS--in consultation with 
CMS and CDC--develop a strategy to capture more complete data on 
confirmed COVID-19 cases and deaths in nursing homes retroactively to 
January 1, 2020. As of February 2021, this recommendation had not been 
implemented. We maintain that implementing this recommendation could 
help fill important gaps in the Federal Government's understanding of, 
and transparency around, data on COVID-19 in nursing homes.

    Similarly, in our March CARES Act report (see GAO-21-387), we noted 
that HHS does not publicly report data showing vaccination rates 
specifically for nursing homes and does not have complete vaccination 
data for nursing homes not participating in the Pharmacy Partnership 
for Long-Term Care Program. As a result, it is unclear to what extent 
efforts to vaccinate nursing home residents have been successful, and 
it may be difficult to use these data to improve ongoing and future 
vaccination efforts for the nursing home population. We made two 
recommendations to address this issue:

     1.  The Secretary of HHS should ensure that the Director of the 
CDC collects data specific to the COVID-19 vaccination rates in nursing 
homes and makes these data publicly available to better ensure 
transparency and that the necessary information is available to improve 
ongoing and future vaccination efforts for nursing home residents and 
staff.

     2.  The Secretary of HHS should ensure that the Administrator of 
CMS, in consultation with the CDC, requires nursing homes to offer 
COVID-19 vaccinations to residents and staff and design and implement 
associated quality measures.

    We note that, on April 8, 2021, CMS published a proposed rule 
related to these recommendations (see previous response to Wyden Q3).

    Question. It has been noted that a nursing home's star rating has 
little to no correlation to its COVID infection rates. Nursing homes 
across the country have been overwhelmingly shut down for the larger 
part of the past year. However, about a third of COVID deaths in the 
U.S. have been from within largely closed facilities. It is also widely 
noted that isolation of nursing home residents had little to do with 
infection control, and that the best indicator of COVID in a nursing 
home was simply community spread. Mr. Dicken, what are your preliminary 
recommendations to protect long-term care residents from nearly the 
same impacts of COVID community-spread of those outside a nursing 
facility?

    Answer. We maintain the importance of our four CARES Act report 
recommendations related to nursing homes for improving the Federal 
response to COVID-19 in nursing homes and protecting nursing home 
residents from the impacts of COVID-19. These recommendations, which 
remain open, are:

     1.  The Secretary of HHS should ensure that the Director of the 
CDC collects data specific to the COVID-19 vaccination rates in nursing 
homes and makes these data publicly available to better ensure 
transparency and that the necessary information is available to improve 
ongoing and future vaccination efforts for nursing home residents and 
staff.

        Source: GAO-21-387, published Mar. 31, 2021.

     2.  The Secretary of HHS should ensure that the Administrator of 
CMS, in consultation with the CDC, requires nursing homes to offer 
COVID-19 vaccinations to residents and staff and design and implement 
associated quality measures.

        Source: GAO-21-387, published Mar. 31, 2021.

     3.  The Administrator of CMS should quickly develop a plan that 
further details how the agency intends to respond to and implement, as 
appropriate, the 27 recommendations in the final report of the Nursing 
Home Commission, which CMS released on September 16, 2020. Such a plan 
should include milestones that allow the agency to track and report on 
the status of each recommendation; identify actions taken and planned, 
including areas where the CMS determined not to take action; and 
identify areas where the agency could coordinate with other Federal and 
nonfederal entities.

        Source: GAO-21-191, published Nov. 30, 2020.

     4.  The Secretary of HHS, in consultation with CMS and CDC, should 
develop a strategy to capture more complete data on confirmed COVID-19 
cases and deaths in nursing homes retroactively back to January 1, 
2020, and to clarify the extent to which nursing homes have reported 
data before May 8, 2020. To the extent feasible, this strategy to 
capture more complete data should incorporate information nursing homes 
previously reported to CDC or to State or local public health offices.

        Source: GAO-20-701, published Sept. 21, 2020.

    Additionally, GAO currently has ongoing work looking at which 
nursing home characteristics, if any, affect the likelihood that a home 
experienced a COVID-19 outbreak. If you would like, we would be happy 
to follow up with your staff to further discuss this issue. We are also 
aware of ongoing work from HHS OIG that will describe the 
characteristics of the nursing homes that were hardest hit by the 
pandemic (OEI-02-20-00490). This work should help provide clarity 
regarding factors associated with nursing home COVID-19 outbreaks, as 
studies published to date have had mixed results.

                                 ______
                                 
            Questions Submitted by Hon. Robert P. Casey, Jr.
    Question. To receive Medicare and Medicaid funding, nursing homes 
must meet minimum Federal quality and safety standards and must also 
submit annual cost reports. According to the Government Accountability 
Office (GAO), these ``cost reports are the only publicly available 
source of financial data for many [nursing facilities].'' In 2016, GAO 
found that while the Centers for Medicare and Medicaid Services 
collects information on nursing home revenue, it is not doing enough to 
ensure that the information is both accurate and accessible to the 
public.

    In light of the pandemic, and the importance of ensuring that 
Federal dollars are spent on things like resident care, infection 
control, and ensuring an adequate workforce, how important is this cost 
information and what can we do to ensure that it is accurately and 
adequately reported?

    Answer. As the question notes, GAO's 2016 report (GAO-16-700) made 
two recommendations related to the issue of Skilled Nursing Facility 
(SNF) expenditure data. Both of these recommendations remain open and 
have not been implemented by CMS (see below). GAO maintains the 
importance of making these data more accurate and accessible to the 
public. While we have not specifically reviewed these issues in the 
context of the COVID-19 pandemic, in our COVID-19 work we have made 
similar recommendations that, if implemented, would improve the 
transparency of nursing home information to the public, including 
nursing home data on COVID-19 vaccinations of residents and staff.

        Recommendation 1: To improve the accessibility and reliability 
        of SNF expenditure data, the Acting Administrator of CMS should 
        take steps to improve the accessibility of SNF expenditure 
        data, making it easier for public stakeholders to locate and 
        use the data.

        Status: The agency concurred with this recommendation in 2016 
        and Stated that it would review the feasibility of increasing 
        the accessibility of this data. However, in August 2017, HHS 
        told GAO that it now believes that the cost of implementing 
        this recommendation would outweigh its benefits. HHS confirmed 
        in July 2019 that its position on this recommendation has not 
        changed. GAO continues to maintain that data on SNFs' relative 
        expenditures should be readily accessible to the public to 
        ensure transparency in SNF expenditures. As of November 2020, 
        HHS officials have not informed us of any actions taken to 
        implement this recommendation.

        Recommendation 2: To improve the accessibility and reliability 
        of SNF expenditure data, the Acting Administrator of CMS should 
        take steps to ensure the accuracy and completeness of SNF 
        expenditure data.

        Status: CMS did not concur with this recommendation. HHS 
        reported in 2016 that the amount of time and resources to 
        verify the accuracy and completeness of SNF expenditure data 
        could be substantial, without assurance of benefit to the 
        agency and the public. However, during the course of our work, 
        GAO found that CMS uses this expenditure data to update overall 
        SNF payment rates, in addition to using it for more general 
        purposes. Without taking steps to ensure the accuracy and 
        completeness of expenditure data, CMS risks developing SNF 
        payments rates that are based on unreliable data. As of 
        November 2020, HHS officials have not informed us of any 
        actions taken to implement this recommendation.

                                 ______
                                 
Prepared Statement of David Gifford, M.D., MPH, Chief Medical Officer, 
  American Health Care Association/National Center for Assisted Living
    Chairman Wyden, Ranking Member Crapo, and distinguished members of 
the Senate Finance Committee, thank you for making nursing homes and 
long-term care (LTC) providers a priority as you examine how COVID-19 
has impacted the Nation. The American Health Care Association and the 
National Center for Assisted Living (AHCA/NCAL) appreciates the 
opportunity to share our perspective regarding caring for seniors in 
nursing homes amid the current COVID-19 crisis.

    AHCA/NCAL represents more than 14,000 non-profit and proprietary 
nursing homes, assisted living communities, and homes for individuals 
with intellectual and developmental disabilities. The 2.5 million 
Americans served in LTC facilities every day are some of the most 
threatened by the SARS-coV-2 coronavirus (COVID-19).

    LTC facilities (including nursing homes and other congregate 
facilities for older adults) have been considered the epicenter of the 
pandemic. As a geriatrician and the chief medical officer for AHCA/
NCAL, I can attest that COVID-19 is the greatest tragedy to impact our 
residents and their families. Over 635,000 nursing home residents have 
been infected and more than 130,000 have died.\1\ This virus has also 
affected health care workers, with over half-a-million nursing home 
staff becoming infected and over 1,600 having succumbed to the virus 
to-date.\2\
---------------------------------------------------------------------------
    \1\ CDC Nursing Home COVID-19 Data Dashboard. Accessed on March 13, 
2021 at https://www.cdc.gov/nhsn/covid19/ltc-report-overview.html.
    \2\ CDC Nursing Home COVID-19 Data Dashboard. Accessible at https:/
/www.cdc.gov/nhsn/covid19/ltc-report-overview.html.

    In addition, the pandemic has taken an emotional and physical toll 
on residents, patients and staff. For nearly a year, family members 
were unable to visit. Residents could not leave their rooms. They could 
not see the smiles of the nurses and aides caring for them, hidden 
behind masks. Our dedicated staff members did everything they could to 
keep residents safe, engaged, and happy. But at the same time, they 
constantly worried about becoming ill and/or infectingtheir loved ones 
at home or their residents. Undoubtedly, this virus will leave 
---------------------------------------------------------------------------
psychological scars for many that will last a lifetime.

    It is critical that we figure out what happened, why it happened, 
and what we can do to keep it from ever happening again.
                        the nature of the virus
    Nursing home residents are at the highest risk for complications 
due to COVID-19. More than half are over the age 85 and suffer from 
multiple chronic diseases, including dementia. According to the Centers 
for Disease Control and Prevention (CDC), compared to younger 
individuals, the risk of COVID-19 infections among the age group of our 
residents is two times higher, but the risk of hospitalization is 80 
times higher, and the risk of death is 7,900 times higher.\3\
---------------------------------------------------------------------------
    \3\ CDC Risk for COVID-19 Infection, Hospitalization, and Death By 
Age Group. Updated February 18, 2021. Accessed on March 13, 2021 at 
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-
discovery/hospitalization-death-by-age.html.

    Nursing home residents experienced a 20-percent mortality rate with 
COVID-19--the highest of any other infection or disease we have ever 
faced. A similarly high rate of infection and death was seen around the 
world among older adults living in LTC facilities. Researchers tracking 
COVID-19 data in the United States \4\ and world-wide \5\ consistently 
found that LTC residents made up a small percentage of total cases yet 
were a disproportionate share of each country's deaths in 2020.
---------------------------------------------------------------------------
    \4\ Kaiser Family Foundation. COVID-19: Long-term Care Facilities. 
Accessed on March 13, 2021 at CDC, Risk for COVID-19 Infection, 
Hospitalization, and Death By Age Group. Updated February 18, 2021. 
Accessible at https://www.cdc.gov/coronavirus/2019-ncov/covid-data/
investigations-discovery/hospitalization-death-by-age.html.
    \5\ Mathews A.W., Douglas J., Kamp J., and Yoon D. COVID-19 Stalked 
Nursing Homes Around the World. Wall Street Journal. Published on line 
on December 31, 2020. Accessed at https://www.wsj.com/articles/covid-
19-stalked-nursing-homes-around-the-world-11609436215.

    It is important to understand the nursing home setting. Residents 
depend on our nurses, aides, housekeepers, dietary staff and therapists 
to help them with daily activities like eating, getting dressed and 
bathing, and this care assistance often requires very close contact for 
prolonged periods. Social distancing was not an option in long-term 
---------------------------------------------------------------------------
care.

    As we now know, COVID-19 does not act like most respiratory 
viruses. It commonly spreads through asymptomatic and pre-symptomatic 
carriers,\6\ making it extremely difficult for providers to prevent its 
entry and spread in LTC facilities. The incubation period for the virus 
is longer than most viruses (up to 14 days). The length of a person's 
infectious period (i.e., the ability to spread to others) is also 
longer than typical respiratory viruses (up to 10 days). Worst of all, 
it was found to have an airborne component of spread.\7\ All these 
characteristics were not known early on during the pandemic. As a 
result, many early recommendations from public health officials were 
incorrect and therefore, ineffective at preventing spread.
---------------------------------------------------------------------------
    \6\ Johansson M.A., Quandelacy T.M., Kada S., et al. SARS-CoV-2 
Transmission From People Without COVID-19 Symptoms. JAMA Network Open. 
2021;4(1):e2035057; doi:10.1001/jamanetworkopen.2020.35057.
    \7\ CDC Science Brief: SARS-CoV-2 and Potential Airborne 
Transmission, updated Oct. 5, 2020, accessible at https://www.cdc.gov/
coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html.
---------------------------------------------------------------------------
              changing and conflicting government guidance
    The Centers for Medicare and Medicaid Services (CMS) and the CDC 
tried to keep pace with the evolving information about COVID-19, 
issuing numerous requirements and guidance to nursing homes at an 
unprecedented speed. Since the implementation of the public health 
emergency,

    CMS and CDC combined have released 55 major new requirements or 
guidance to nursing homes in the areas of infection control, testing 
and the use of personal protective equipment (PPE), or on average, at 
least one per week. (This does not count the frequent minor updates or 
modifications to guidance, nor all the Medicare and Medicaid payment 
changes. Additionally, it does not include all the CMS guidance related 
to 1135 waivers, the Five-Star rating system, and survey frequency. 
There was also myriad guidance from other agencies, such as the 
Department of Labor and the Occupational Health and Safety 
Administration.)

    In addition, many States issued orders and recommendations, which 
often conflicted with other States or Federal guidance. This ever 
evolving and conflicting guidance, scattered across multiple websites 
and hundreds of pages, made it nearly impossible for providers to 
follow consistent best practices to mitigate the spread of the virus.

    Even though public health officials constantly churned out new 
guidance, it was often too late and outdated by the time it was issued. 
The timing of some of the major recommendations made by CMS and CDC are 
depicted in the attached timeline (see last page) relative to the 
number of cases and deaths in nursing homes. Early on, the public 
health recommendations focused on a symptoms-based approach. CMS 
required that staff be screened for symptoms and asked staff to stay 
home if they had any one symptom suggestive of COVID-19. However, 
screening only for symptoms meant missing asymptomatic staff who could 
unwittingly spread the virus in the facility. Masks were not 
recommended for use by all staff throughout the facility until almost 4 
months into the pandemic in late June. This allowed the virus to spread 
amongst staff members outside of designated COVID patient care areas. 
Early on and without adequate testing available, residents were 
cohorted based on symptoms, which sometimes resulted in asymptomatic or 
pre-symptomatic residents spreading the virus in what were believed to 
be COVID-free units or rooms.
                            lack of testing
    Nursing home providers found it challenging to access affordable, 
reliable, and timely tests until many months into the pandemic. Due to 
the country's limited testing capabilities in beginning, LTC residents 
were not made a priority for testing. Even when they were made a 
priority by the CDC at the end of April, it was only for residents and 
staff with symptoms, and tests were rarely available. When they were 
available, it often took 5 days or more to receive the results. Testing 
kits and supplies were not sent to nursing homes until August. Routine 
surveillance testing was not required until September, six months after 
the start of the pandemic.

    The lack of adequate and timely testing impaired the ability of 
providers to keep the virus at bay, as asymptomatic and pre-symptomatic 
spread could continue undetected. Even when testing kits became 
available in the fall of 2020, the initial lack of guidance and then 
changing guidance on how to interpret test results between the 
polymerase chain reaction (PCR) and antigen tests further compounded 
the effectiveness of testing to prevent spread.
                personal protective equipment shortages
    Despite caring for the most vulnerable population when it comes to 
COVID-19, LTC facilities were not made a priority for necessary 
equipment. Even after numerous calls for help,\8\ it took months for 
LTC residents and staff to be made the highest priority for PPE. 
Worldwide supply chain issues left providers scrambling to find and 
purchase quality PPE, such as N95 masks, gowns, and gloves. Many 
suppliers delayed or limited the size of providers' orders, and many 
providers got taken by scammers pretending to have legitimate PPE. In 
addition, prices soared.
---------------------------------------------------------------------------
    \8\ COVID-19 Timeline, accessible at https://saveourseniors.org/
timeline/; accessed on March 13, 2021.

    In many circumstances, staff had to use their ingenuity to make 
their own masks, gowns and face shields. I recall getting calls one 
night asking which type of material would be best for masks, and on a 
weekend asking if rain ponchos work better as gowns than trash bags. 
Academic research found that this lack of PPE was correlated with more 
cases and deaths in nursing homes reporting PPE shortages.\9\
---------------------------------------------------------------------------
    \9\ McGarry B.E., Grabowski D.C., Barnett M.L. Severe Staffing and 
Personal Protective Equipment Shortages Faced By Nursing Homes During 
the COVID-19 Pandemic. Health Affairs (Millwood). 2020 Oct;39(10):1812-
1821; doi: 10.1377/hlthaff.2020.01269. Epub 2020 Aug 20. PMID: 
32816600.

    In May, the Federal Emergency Management Agency (FEMA) organized 
two shipments of PPE supplies that would each cover the needs of a 
nursing home for one week.\10\ The first shipment arrived in mid-May to 
early June, and the second shipment in July. These two shipments were 
an amazing logistical feat but did not start until 10-12 weeks into the 
pandemic. Also, they did not contain any N95 masks given the continued 
worldwide shortages. For many, the PPE waswelcomed and lifesaving, but 
there were several shipments that included PPE that either could not be 
used,\11\, \12\ was past its expiration date, or did not 
meet CDC or CMS standards.\13\ In one case a provider relayed to me, 
CMS inspectors would not use the PPE when offered to them during their 
on-site infection control inspection.
---------------------------------------------------------------------------
    \10\ FEMA press release. ``Coronavirus pandemic response: PPE 
packages for Nursing Homes,'' released May 2, 2020. Accessed on March 
14, 2021 at https://www.fema.gov/fact-sheet/coronavirus-pandemic-
response-ppe-packages-nursing-homes.
    \11\ Joran Rau. ``Federal Help Falters as Nursing Homes Run Short 
of Protective Equipment.'' Kaiser Health News, posted June 11, 2020; 
accessible at https://khn.org/news/federal-help-falters-as-nursing-
homes-run-short-of-protective-equipment/.
    \12\ Priscilla Alvarez and Daniella Diaz. ``Nursing homes receive 
defective equipment as part of Trump administration supply 
initiative.'' CNN Politics, updated Thursday June 11, 2020; accessible 
at https://www.cnn.com/2020/06/10/politics/nursing-homes-ppe-defective-
equipment-fema/index.html.
    \13\ Katie Smith Sloan, CEO of LeadingAge, Letter to Vice President 
on June 11, 2020; accessible at https://www.leadingage.org/sites/
default/files/LeadingAge%20Pence%20Letter%20611
20_final.pdf.
---------------------------------------------------------------------------
                     the impact of community spread
    Due to the nature of how COVID-19 spreads, the lack of PPE and 
testing, and ever shifting guidance, it is not surprising that the 
principal factor leading to COVID-19 outbreaks in nursing homes has 
been repeatedly shown to be related to the amount of spread in the 
surrounding community. Even the best nursing homes with the most 
rigorous infection control practices could not stop this highly 
contagious, invisible enemy.\14\ Academic experts at Harvard 
University,\15\ Brown University \16\ and the University of Chicago 
\17\,\18\ all found that the primary predictor of a nursing 
home experiencing an outbreak is the prevalence of COVID-19 in the 
surrounding community. Other factors that predicted outbreaks related 
to increased human-to-human interaction, which clearly increases the 
chance the virus can spread. These factors meant larger facilities, 
especially those in urban areas where there is higher proportion of 
minority residents, were more likely to experience outbreaks.
---------------------------------------------------------------------------
    \14\ Opinion by David C. Grabowski, R. Tamara Konetzka, and Vincent 
Mor. Opinion: We can't protect nursing homes from COVID-19 without 
protecting everyone. Washington Post. Published June 25, 2020; 
available at https://www.washingtonpost.com/opinions/2020/06/25/we-
cant-protect-nursing-homes-covid-19-without-protecting-everyone/.
    \15\ Abrams H.R., Loomer L., Gandhi A., Grabowski D.C. 
Characteristics of U.S. Nursing Homes With COVID-19 Cases. J Am Geriatr 
Soc. 2020 Aug;68(8):1653-1656; doi: 10.1111/jgs.16661. Epub 2020 Jul 7.
    \16\ White E.M., Kosar C.M., Feifer R.A., Blackman C., et al. 
Variation in SARS-CoV-2 Prevalence in U.S. Skilled Nursing Facilities. 
J Am Geriatr Soc. 2020 Oct;68(10):2167-2173; doi: 10.1111/jgs.16752. 
Epub 2020 Aug 21. PMID: 32674223 PMCID: PMC7404330 DOI: 10.1111/
jgs.16752.
    \17\ Konetzka R.T., Gorges R.J. Nothing Much Has Changed: COVID-19 
Nursing Home Cases and Deaths Follow Fall Surges. J Am Geriatr Soc. 
2021 Jan;69(1):46-47; doi: 10.1111/jgs.16951. Epub 2020 Nov 20.
    \18\ Gorges R.J., Konetzka R.T. Factors Associated With Racial 
Differences in Deaths Among Nursing Home Residents With COVID-19 
Infection in the U.S. JAMA Network Open. 2021 Feb 1;4(2):e2037431; doi: 
10.1001/jamanetworkopen.2020.37431. PMID: 33566110.

    The same academic researchers could not find an association with 
COVID-19 outbreaks and other characteristics, such as the facility's 
Five-Star Rating on Nursing Home Compare; whether the facility had a 
prior violation related to infection control; or whether it was for-
profit, part of a chain, or had a high Medicaid census. This 
relationship of COVID-19 cases in nursing homes mirroring the 
prevalence in the community continued through the fall based on 
analyses by the Kaiser Family Foundation \19\ and CDC.\20\
---------------------------------------------------------------------------
    \19\ Priya Chidambaram and Rachel Garfield. Patterns in COVID-19 
Cases and Deaths in Long-Term Care Facilities in 2020. Kaiser Family 
Foundation. Coronavirus. Published: January 14, 2021; https://
www.kff.org/coronavirus-covid-19/issue-brief/patterns-in-covid-19-
cases-and-deaths-in-long-term-care-facilities-in-2020/.
    \20\ Bagchi S., Mak J., Li Q., et al. Rates of COVID-19 Among 
Residents and Staff Members in Nursing Homes--United States, May 25-
November 22, 2020. MMWR Morb Mortal Wkly Rep 2021;70:52-55; doi: http:/
/dx.doi.org/10.15585/mmwr.mm7002e2.

    With hindsight it is easy to criticize public officials and health 
care providers for failures during the pandemic. This is unfair, given 
the lack of knowledge about this virus. However, what was evident was 
that the LTC community was left behind, forgotten, or even blamed. This 
further demoralized our health care heroes in LTC who were giving their 
all and risking their lives as well as their family members' lives but 
---------------------------------------------------------------------------
received inadequate support.

    It is critical that we figure out what we can do to prevent such 
tragedy from ever happening again. But in order to move forward, we 
must also reflect on the long-standing challenges within the LTC 
profession that COVID-19 exposed and exacerbated. Providers acknowledge 
that we can and need to do better to meet the needs of our Nation's 
seniors--continuous quality improvement is part of who we are.

    Let me take a moment to highlight several historical challenges 
facing long term care that the pandemic further exposed. These include 
staffing, health care disparities, infection control, and 
reimbursement.
                            workforce crisis
    Long-term care was already dealing with a workforce shortage prior 
to COVID, and the pandemic has only magnified the crisis due to staff 
members getting sick, having to isolate, or a lack of childcare 
options. At the same time, the pandemic required numerous new tasks 
(e.g., screening all personnel upon entry, reporting cases daily, 
serving meals in rooms, donning PPE for every resident) and more one-
on-one care to help prevent spread, all requiring more staff. We 
commonly heard the phrase ``all-hands-on deck'' to help meet the 
residents' needs and new recommendations and guidance.

    During the pandemic, AHCA/NCAL urged governors to help address the 
workforce shortage by outlining strategies in a roadmap for States in 
May 2020.\21\ We also developed free online courses to help train 
temporary caregivers (nurse aides and feeding assistants) to help fill 
the gap the pandemic created. Additionally, AHCA/NCAL urged Congress 
and the administration to direct financial aid to long term care 
facilities, so that providers could use those resources to respond to 
the crisis, including by hiring more staff and offering hero pay. In a 
survey of nursing home providers conducted in November 2020, 70 percent 
of nursing homes had hired additional staff and nine out of 10 asked 
staff to work overtime and provided hero pay.\22\
---------------------------------------------------------------------------
    \21\ AHCA/NCAL Long Term Care Workforce Roadmap for Governors and 
States; https://www.ahcancal.org/Survey-Regulatory-Legal/Emergency-
Preparedness/Documents/COVID19/AHCANCAL-Workforce-Roadmap.pdf.
    \22\ AHCA Survey State of the Nursing Home Industry; https://
www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/State-
of-Nursing-Home-Industry_Dec2020.pdf.

    We need ongoing staff support as this pandemic continues, but we 
also need a more long-term solution. AHCA/NCAL has been highlighting 
this workforce crisis for years, including testifying to Congress twice 
in 2019. It is time that we address this. We need a comprehensive 
strategy to recruit more health care heroes to serve in long-term care.
                           infection control
    As described earlier, prior infection citations have not been shown 
to be associated with COVID-19 outbreaks or cases. However, nursing 
homes have been cited for infection control practices historically.\23\ 
These trends led CMS to issue an extensive set of new regulations in 
November 2016 phased in over 3 years, including the requirement for a 
designated infection preventionist in every nursing home starting in 
November 2019.\24\ These new requirements and regulations were just 
taking effect when the pandemic hit.
---------------------------------------------------------------------------
    \23\ GAO. Infection Control Deficiencies Were Widespread and 
Persistent in Nursing Homes Prior to COVID-19 Pandemic. GAO-20-576R. 
Published: May 20, 2020. Publicly Released: May 20, 2020; https://
www.gao.gov/products/gao-20-576r.
    \24\ Medicare and Medicaid Programs: Reform of Requirements for 
Long-Term Care Facilities. A Rule by the Centers for Medicare and 
Medicaid Services on 10/04/2016 published in Federal Register; 
available at https://www.federalregister.gov/documents/2016/10/04/2016-
23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-
term-care-facilities.

    Unfortunately, many infection preventionists became ill or had to 
isolate following exposure or presenting with symptoms. This 
highlighted the importance of having the infection preventionist 
position met not by a single person but adjusted based on the size and 
needs of the facility. A large nursing home with 300 residents has 
different infection control demands than a small, rural nursing home 
with 20 residents. AHCA supported the infection preventionist 
regulations anddeveloped a certification program to train over 3,000 
infection preventionists before they went into effect. However, the 
nursing shortage continues to make it challenging to identify infection 
preventionists, as many are hired away by hospitals. To meet the need 
for infectionpreventionists, we need help with recruiting and retaining 
registered nurses (RNs) to serve in this role.
                          disparities in care
    The pandemic has disproportionately impacted minority populations 
more than others. This has been no different in nursing 
homes.\25\, \26\ The disparities in care outcomes were known 
prior to COVID.\27\ Academic experts who have analyzed the differences 
in outcomes among African American and Latino residents in long-term 
care find the disparities to be related to both the overall quality of 
the facility and the Medicaid reimbursement challenges.\28\, 
\29\ This has led several academic and policy experts to call for more 
resources and changes to Medicaid to address these 
disparities.\30\, \31\ As a country, we need to step up and 
make sure that minority populations have equitable health-care coverage 
and supports, including in long-term care. This in part, means properly 
funding health-care programs like Medicaid, so that long-term care 
providers who care for people of color have the staffing and other 
resources needed to meet their residents' needs.
---------------------------------------------------------------------------
    \25\ Gorges R.J., Konetzka R.T. Factors Associated With Racial 
Differences in Deaths Among Nursing Home Residents With COVID-19 
Infection in the U.S. JAMA Network Open. 2021 Feb 1;4(2):e2037431; doi: 
10.1001/jamanetworkopen.2020.37431. PMID: 33566110.
    \26\ Li Y., Cen X., Cai X., Temkin-Greener H. Racial and Ethnic 
Disparities in COVID-19 Infections and Deaths Across U.S. Nursing 
Homes. J Am Geriatr Soc. 2020 Nov;68(11):2454-2461; doi: 10.1111/
jgs.16847. Epub 2020 Sep 28.
    \27\ Mack D.S., Jesdale B.M., Ulbricht C.M., Forrester S.N., 
Michener P.S., Lapane K.L. Racial Segregation Across U.S. Nursing 
Homes: A Systematic Review of Measurement and Outcomes. Gerontologist. 
2020 Apr 2;60(3):e218-e231; doi: 10.1093/geront/gnz056. PMID: 31141135.
    \28\ Campbell L.J., Cai X., Gao S., Li Y. Racial/Ethnic Disparities 
in Nursing Home Quality of Life Deficiencies, 2001 to 2011. Gerontol 
Geriatr Med. 2016 Jun 6;2:2333721416653561; doi: 10.1177/
2333721416653561. eCollection 2016 Jan-Dec. PMID: 27819015.
    \29\ Barton Smith D., Feng Z., Fennell M.L., et al. Separate and 
unequal: Racial segregation and disparities in quality across U.S. 
nursing homes. Health Aff (Millwood). Sep-Oct 2007;26(5):1448-58; doi: 
10.1377/hlthaff.26.5.1448. PMID: 17848457 DOI: 10.1377/
hlthaff.26.5.1448.
    \30\ Ibid #27.
    \31\ Grabowski D.C. Strengthening Nursing Home Policy for the 
Postpandemic World: How Can We Improve Residents' Health Outcomes and 
Experiences? Commonwealth Fund; issue briefs August 20, 2020; https://
www.commonwealthfund.org/publications/issue-briefs/2020/aug/
strengthening-nursing-home-policy-postpandemic-world.
---------------------------------------------------------------------------
                            financial crisis
    Prior to the COVID-19 pandemic, Medicaid underfunding plagued 
nursing homes for years. More than 60 percent of all nursing home 
residents rely on Medicaid to cover their daily care. However, Medicaid 
reimbursements only cover 70 to 80 percent of the actual cost of care 
in a nursing home. The intense needs of our residents require dedicated 
staff to provide hands-on care and consequently, labor makes up an 
enormous proportion of everyday expenses (roughly 70 percent). The 
chronic Medicaid underfunding makes it challenging for providers to 
offer competitive wages and benefits and make other investments in 
their workforce.

    Over the last year, long-term care facilities have faced 
skyrocketing costs. Providers have dedicated extensive resources to 
fighting COVID-19. The costs associated with routine testing, PPE, and 
staffing have pushed many facilities to the brink. The Provider Relief 
Fund created by Congress has been a lifeline, allowing nursing homes to 
stay open and providers to purchase resources to protect their 
residents and staff. However, nursing homes only received approximately 
$13 billion from the Provider Relief Fund, or roughly 7 percent of the 
fund's total. This is less than half of what nursing homes spent on PPE 
and additional staffing alone in 2020 ($30 billion), and these 
additional costs are expected to continue in 2021 as the pandemic 
lingers.

    In addition, revenue has significantly declined due to fewer 
patients coming from the hospital as well as fewer potential residents 
seeking long term care. Nationally, nursing home occupancy 
significantly dropped from 80.2 percent in January 2020 to 68.2 percent 
in March 2021.\32\ This has resulted in $11.3 billion in losses to 
nursing homes in 2020 and is projected to increase in 2021 to $22.6 
billion. AHCA/NCAL did an extensive analysis estimating nursing 
homefinancials and found that in combining anticipated COVID costs and 
projected losses, the industry expects to lose $94 billion over a 2-
year period (2020-2021).\33\
---------------------------------------------------------------------------
    \32\ AHCA analysis of CDC NHSN data; accessible at https://
www.ahcancal.org/Data-and-Research/Pages/default.aspx; downloaded on 
March 14, 2021.
    \33\ AHCA Issue Brief: Protect Access to Long Term Care for 
Vulnerable Residents; https://d3dkdvqff0zqx.cloudfront.net/groups/ahca/
attachments/protect%20access%20to%20long%20
term%20care_ib.pdf.

    Today, thousands of LTC facilities are on the verge of collapse, 
with more 1,600 nursing homes in danger of closing their doors this 
year. This has real consequences for residents and their families. 
Again, most residents are older adults living with multiple underlying 
health conditions, and they require a high-level of specialized care. 
Closures leave residents displaced from their long-standing communities 
and loved ones. Closures also reduce options for quality care, 
---------------------------------------------------------------------------
especially in rural areas.

    In order to protect access to long-term care for vulnerable seniors 
and improve staffing issues, Medicaid reimbursement needs to be 
reformed as numerous academic experts have advised.\34\, 
\35\, \36\ Medicaid reimbursement rates must catch up with 
the cost of care. Nursing homes need adequate funding and resources in 
order to provide quality care. We urge policy-makers and stakeholders 
to work toward long-term solutions that tackle this systemic issue.
---------------------------------------------------------------------------
    \34\ Grabowski D.C., Mor V. Nursing Home Care in Crisis in the Wake 
of COVID-19. JAMA. 2020 Jul 7;324(1):23-24; doi: 10.1001/
jama.2020.8524. PMID: 32442303 DOI: 10.1001/jama.2020.8524.
    \35\ Grabowski D.C. Strengthening Nursing Home Policy for the 
Postpandemic World: How Can We Improve Residents' Health Outcomes and 
Experiences? Commonwealth Fund; issue briefs August 20, 2020; https://
www.commonwealthfund.org/publications/issue-briefs/2020/aug/
strengthening-nursing-home-policy-postpandemic-world.
    \36\ R. Tamara Konetzka, Caring for Seniors Amid the COVID-19 
Crisis. Testimony Before the United States Senate Special Committee on 
Aging. May 21, 2020; accessible at https://www.aging.senate.gov/imo/
media/doc/SCA_Konetzka_05_21_20.pdf.
---------------------------------------------------------------------------
           how we move forward: the care for our seniors act
    The pandemic has led the nursing home sector to reflect what can be 
done to prevent such tragedy from ever happening again and how to 
address longstanding challenges COVID-19 exposed. After reviewing the 
evidence, expert recommendations, and the Commission for Safety and 
Quality in Nursing Homes report,\37\ AHCA and LeadingAge announced the 
Care for Our Seniors Act.\38\ This is a comprehensive plan aimed at 
offering solutions that will improve the quality of care in our 
Nation's nursing homes as we begin to look towards a post COVID-19 
environment. This plan recommends policies and steps to improve 
clinical care, strengthen and support our workforce, improve oversight, 
and modernize our physical structures. Specifically, we are supporting:
---------------------------------------------------------------------------
    \37\ Independent Nursing Home COVID-19 Commission Findings Validate 
Unprecedented Federal Response. Issued on September 16, 2020; available 
at https://www.cms.gov/newsroom/press-releases/independent-nursing-
home-covid-19-commission-findings-validate-unprecedented-federal-
response.
    \38\ AHCA and LeadingAge's Care For Our Seniors Act; available at 
www.ahcancal.org/solutions.
---------------------------------------------------------------------------
Clinical--Enhance Quality Care:
      24-hour R.N.: We support a new Federal requirement that each 
nursing home have an R.N. on staff 24 hours a day and provide 
recommendations on how to effectively implement this requirement.
      Enhanced infection preventionist: We will help establish an 
updated guideline for staffing infection preventionists in each nursing 
home based on proven, successful strategies. This includes proper 
funding and workforce availability to effectively implement meaningful, 
sustained changes.
      Minimum 30-day supply of PPE: We support efforts to require a 
minimum supply of PPE in nursing homes, which will be supported by 
ongoing Federal/State stockpiles with PPE that is acceptable for 
health-care use.
Workforce--Strengthen and Support Front-line Caregivers:
      Recruit and retain more long-term care workers: We support 
implementing a multi-phase tiered approach leveraging Federal, State, 
and academic entities. This includes loan forgiveness for new graduates 
who work in LTC, tax credits for licensed LTC professionals, programs 
for affordable housing and childcare assistance, and increased 
subsidies to professionals' schools whose graduates work in nursing 
homes for at least 5 years.
Oversight--Improve Systems to Be More Resident-Driven
      Survey improvements for better resident care: We support 
development of an effective oversight system and processes that promote 
improved care and protect residents, consistent with CMS standards.
      Chronic poor-performing nursing facilities: The survey system 
needs a process to help turn chronic poor-performing facilities around 
or close the facility. We are proposing a five-step process to address 
such facilities.
      Publicly report customer satisfaction: Nursing homes are the 
only health-care setting in which CMS collects and publicly reports 
quality data that does not include customer satisfaction. We recommend 
adding this measure to the government's Five-Star rating system to help 
monitor the quality of a nursing home for family members and guide 
consumer choice.
Structural--Modernize for Resident Dignity and Safety
      Shift to private rooms: The average nursing home is around 40 to 
50 years old. The traditional care models are no longer considered 
appropriate to provide 
person-centered care. One central aspect of this shift is a greater 
emphasis on autonomy, dignity and privacy. Private rooms also support 
infection control best practices. We support the development of a 
national study producing data on conversion costs and a recommended 
approach to make this shift.

    Long-lasting transformation that will protect our residents 
requires a considerable investment in the LTC profession. As a health-
care provider that relies almost entirely on government reimbursement 
(Medicare and Medicaid), nursing homes cannot make substantial reforms 
on their own. They need the support of Federal and State policy-makers 
and resources.
                               conclusion
    Long-term care providers welcome a national discussion regarding 
how we can improve in light of the COVID-19 pandemic. We urge the 
Senators of this committee and the entire Congress to recognize the 
nature of this virus and that we need a collaborative approach to 
address longstanding challenges in our Nation's nursing homes.

    Focusing solely on regulations fails to recognize the cause of this 
crisis, nor does it help solve it. The reality is that many of these 
outbreaks have occurred because nursing homes were located in 
communities with high rates of spread and because long-term care 
residents and staff were not prioritized by public health officials, 
leaving providers scrambling for testing, PPE, and staffing resources. 
Just like hospitals, we called for help from the very beginning. But 
unlike hospitals, our calls often went unanswered or came too late. In 
our case, it has been difficult to get anyone to listen. Prioritizing 
long-term care facilities in emergency situations is key, as we have 
seen in other emergencies, such as natural disasters.

    Despite a year of tragedy, a virus that will linger well into the 
future, and historic challenges within long-term care, I remain 
optimistic. We have three remarkably safe and effective vaccines. 
Nursing home residents and staff were made a priority to receive the 
vaccine by the CDC and the vast majority of Governors. As a result, 
nursing home cases and deaths have declined dramatically since mid-
December and faster than the general population. This has allowed CDC 
and CMS to update guidance to allow more in-person visitations. We are 
elated to see families and residents reunited. Making our nursing homes 
a top priority for the vaccine demonstrates the power of putting long-
term care and our Nation's seniors first.

    I want to end by saying that our hearts go out to the residents and 
their family members who have suffered through the past year, separated 
from each other--in some cases forever. Our thoughts also go to the 
long-term caregivers who have given their all this past year, often 
without the recognition they deserve.

    I have spoken with providers, families and other stakeholders who 
all agree that the health-care system needs to be better aligned to 
achieve the outcomes we all want. If any good can come out of the 
pandemic, we are hopeful that it can serve as the catalyst needed to 
institute meaningful change.

    On behalf of the residents, their families and the staff in nursing 
homes across the country, thank you for your dedication and leadership 
to tackle the long-term care needs of our seniors and individuals with 
disabilities. Your ongoing help and support mean more now than ever 
before. Ensuring that essential and necessary resources are provided to 
long-term care providers is critical to protecting our Nation's most 
vulnerable. We look forward to having constructive discussions on 
solutions with you to combat COVID-19 and usher in a stronger long-term 
care system.

TIMELINE:

COVID-19 AND NURSING HOMES
Despite repeated calls for help, nursing homes did not receive 
resources or priority for months. Even then, the high amount of spread 
in surrounding communities made it impossible for nursing homes to 
prevent the virus from entering their facilities. This timeline 
identities major regulatory, policy and resource supports skilled 
nursing facilities (SNFs) received during the pandemic, as compared to 
the timing of cases and deaths.
[GRAPHIC] [TIFF OMITTED] T1721.026

.epsThe Federal Government began collecting and reporting nursing home 
cases and deaths in May 2020. Since the implementation of the public 
health emergency, CMS and CDC combined have released 55 (or on average 
at least one per week) major new requirements or guidance in areas of 
infection control, testing and PPE use. This does not count minor 
guidance updates or modifications nor payment changes.

                                 ______
                                 
     Questions Submitted for the Record to David Gifford, M.D., MPH
                 Questions Submitted by Hon. Ron Wyden
    Question. The Centers for Medicare and Medicaid Services (CMS) 
issued an interim final rule last year that required nursing homes to 
report COVID-19 data to the Centers for Disease Control and Prevention 
on a weekly basis beginning May 17, 2020. These data included COVID-19 
infections, COVID-19 deaths, and the availability of key equipment and 
workers at individual nursing homes. The data have proved to be helpful 
for the public, policy-makers, and industry stakeholders to track the 
pandemic, and related issues, in these care settings. However, to date, 
CMS has not required nursing homes to provide such data prior to May 8, 
2020, despite calls from Senate Democrats to do so. In September 2020, 
the Government Accountability Office (GAO) noted that ``by not 
requiring nursing homes to submit data from the first 4 months of 2020, 
HHS is limiting the usefulness of the data in helping to understand the 
effects of COVID-19 in nursing homes.'' GAO went on to recommend that 
``HHS, in consultation with CMS and CDC, develop a strategy to capture 
more complete data on COVID-19 cases and deaths in nursing homes 
retroactively back to January 1, 2020.''

    Do you support GAO's recommendation? Why or why not? Please briefly 
explain.

    Answer. COVID-19 cases among resident and staff were reported by 
nursing homes to State or local public health agencies since the 
beginning of the pandemic. As pointed out by the GAO, these data 
systems did not readily communicate with CDC or integrate to create a 
national database. As a result, CMS issued an interim final rule 
mandating all Medicare or Medicaid certified nursing homes to submit 
case counts on a weekly basis to the CDC's National Healthcare Safety 
Network (NHSN) system starting in May 2020. This resulted in duplicate 
reporting requirements for nursing homes all because State and Federal 
systems could not communicate effectively.

    We support States making the data they have on COVID-19 case counts 
prior to May 2020 available to the CDC or other Federal agencies for 
research purposes to learn about the pandemic and how to better combat 
the spread of COVID-19. We are not supportive of asking providers to go 
back through their medical records to identify cases and provide data 
they have already provided solely because State and Federal systems are 
not integrated. This would take an extensive amount of time and 
resources away from resident care, shifting the burden of data 
collection onto providers at a time staff are already stretched thin 
due ongoing workforce challenges and the pressures of the pandemic.

    A lesson that should be addressed from this pandemic has been that 
State and Federal public health data systems are underfunded, 
underdeveloped and under-maintained. The public health infrastructure 
needs more Federal funding to modernize their data systems and make 
sure they are integrated. We are currently experiencing the same 
problem with State immunization registries. They do not integrate with 
Federal data systems and long-term care (LTC) pharmacies and providers 
are having to enter duplicate immunization data in State immunization 
registries and CDC Federal registries. This is not a good use of 
health-care staff's time. They should be devoted to making sure 
residents and staff receive the vaccine and monitoring their reaction, 
not entering the same data into multiple systems because the States and 
Federal Governments are not collaborating cohesively.

    Question. A recent paper published by the National Bureau of 
Economic Research noted that people who receive treatment in nursing 
homes owned by private equity firms have worse health outcomes than 
those living in facilities under other ownership structures.\1\ This 
paper adds evidence to reports of worse outcomes associated with 
private equity's investment in the nursing home industry. Nursing homes 
have also become popular investments for real estate investment trusts 
(REITs), which often lease back properties to private equity firms or 
other related parties. The involvement of private equity in the nursing 
home industry has been of interest to the Finance Committee for more 
than a decade, and the role of private equity and for-profit ownership 
in the nursing home industry was raised in testimony and questions at 
the hearing. Several reports from Federal agencies have suggested the 
need for more thorough information on facility 
ownership.\2\, \3\
---------------------------------------------------------------------------
    \1\ https://www.nber.org/papers/w28474.
    \2\ https://oig.hhs.gov/oei/reports/oei-04-11-00591.pdf.
    \3\ https://www.gao.gov/assets/gao-10-710.pdf.

    Please provide a list of all private equity firms and real estate 
investment trusts (REIT) that are currently members of AHCA, or have 
been within the last 5 years. In your response, please include 
instances in which a subsidiary (or an otherwise related party) of a 
private equity firm or REIT--e.g., a nursing home chain owned by a 
private equity company, or that leases a large portion of its 
facilities from a REIT--is an AHCA member, noting the parent company, 
---------------------------------------------------------------------------
controlling entity, or related party.

    Answer. AHCA does not collect information from our members nor have 
access to CMS's Medicare Provider Enrollment, Chain, and Ownership 
System (PECOS) data on private equity, REIT or controlling party 
involvement with nursing homes or ``chain-owned'' nursing homes.

    Question. Section 6101 of the Affordable Care Act (ACA) sought to 
increase ownership transparency within the industry, but to date, the 
provision has not been fully implemented or enforced by the Centers for 
Medicare and Medicaid Services. Does AHCA support the full 
implementation of section 6101?

    Answer. AHCA's background and position on section 6101 of the ACA 
is outlined in our policy memo available at https://www.ohca.org/
uploads/old/ppac_disclosure_of_ownership.pdf. However, clarity on 
definitions and using existing reporting requirements need to be taken 
into consideration so that duplicative reporting is not required. CMS 
did implement transparency reporting requirements in 2011, which 
nursing homes comply with (see: https://www.cms.gov/Medicare-Medicaid-
Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/
ebulletins-providerenrollment-disclosureownership.pdf). We are 
supportive of making this information more easily accessible than CMS 
and many States currently offer.

    Question. Beyond the provisions of section 6101, does AHCA support 
additional transparency into nursing home ownership, financial 
arrangements, use of government funds, and worker pay?

    Answer. AHCA is supportive of transparency on ownership. We believe 
much of the transparency data that many members of the public, policy-
makers and the media are asking for are currently collected. We should 
use the existing data before mandating additional and potentially 
unnecessary data collection efforts.

    Also, we believe the most important issue for residents and their 
families is transparency on the quality of the care being provided, 
regardless of ownership. Proper resources should be devoted to assuring 
that nursing home residents' care is met, which should be reflected in 
transparency of quality outcomes. Creating additional reporting and 
bureaucracy that diverts resources away from resident care is not 
helpful.

    Question. COVID-19's toll on nursing homes has not been limited to 
viral infections. Residents have suffered mentally and physically, and 
had less access to family members and patient advocates. On March 10, 
2021, the Centers for Medicare and Medicaid Services issued new 
guidance that allows for residents to more easily receive visitors. On 
the same day, the Centers for Disease Control and Prevention issued 
Updated Healthcare Infection Prevention and Control Recommendations in 
Response to COVID-19, which stated ``quarantine is no longer 
recommended for residents who are being admitted to a post-acute care 
facility if they are fully vaccinated and have not had prolonged close 
contact with someone with SARS-coV-2 infection in the prior 14 days.'' 
The committee has received written testimony for this hearing from 
medical experts raising concerns that the new guidance may be overly 
permissive, and could put nursing home residents in danger, 
particularly if COVID-19 variants breakthrough vaccine protections. On 
the other hand, some advocates have called for more permissive 
visitation guidelines.

    As a trained physician, do you have any concerns about the guidance 
that was issued?

    Answer. As with all medical care decisions, there are risks and 
benefits to each decision, medication, test or procedure ordered for a 
patient. One needs to balance the risks and benefits, which may not be 
interpreted the same between two different individuals with the same 
situation. In the case of allowing or not allowing visitations, we have 
faced this same dilemma. Allowing visitors could increase the chances 
of viral spread, but not allowing visitors increases the risk of 
isolation and decline in residents. The new guidance we believe takes 
the risks and benefits into consideration. As with each new guidance, 
there remains unanswered questions about how to apply the guidance to 
specific situations. Nursing homes have demonstrated good faith efforts 
to implement each new guidance but will need clarity from time to time 
from CDC. Getting that clarity or not taking into consideration good 
faith efforts to adoption new guidance has been a frustration we have 
heard over and over again from providers.

    Question. Do nursing homes and long-term care facilities need 
additional guidance to properly dial visitation?

    Answer. As we learn more about how the virus spreads, how effective 
preventive measures are as well as the effectiveness of being 
vaccinated, we need CMS and CDC to update their guidance about how 
residents can participate in communal dinning, activities, travel 
outside the facility as well as family visitation. In addition, 
screening and testing procedures currently in place are predicated on 
what we knew last summer and fall prior to vaccination and variants.

    We need CMS and CDC to update guidance on a regular basis but also 
to provide enough lead time for providers to change their practices. 
For example, the reopening guidance went into effect immediately. As a 
result, we had family members showing up at the facility that same day 
demanding entry when the facility perhaps did not have personal 
protective equipment (PPE) for visitors or procedures in place to allow 
safe visitation described in the CMS guidance document.

    Question. Preliminary research conducted by Columbia University 
researchers suggests that the Pfizer and Moderna vaccines were up to 12 
times less effective at neutralizing the B.1.351 COVID-19 variant 
(``South African variant'') than earlier strains of the coronavirus.\4\ 
The researchers also found that convalescent plasma was 9 times less 
effective against the South African variants, leading them to write 
``[t]aken together, the overall findings are worrisome, particularly in 
light of recent reports that both Novavax and Johnson & Johnson 
vaccines showed a substantial drop in efficacy in South Africa.''\5\ 
The researchers went on to write, ``mutationally, this virus is 
traveling in a direction that could ultimately lead to escape from our 
current therapeutic and prophylactic interventions directed to the 
viral spike. If the rampant spread of the virus continues and more 
critical mutations accumulate, then we may be condemned to chasing 
after the evolving SARS-CoV-2 continually, as we have long done for 
influenza virus.''\6\ The Centers for Disease Control and Prevention 
(CDC) has previously found suspected cases of reinfection among nursing 
home residents who previously tested positive for COVID-19.\7\ 
Similarly, a paper published earlier this year in The Lancet suggested 
that a resurgence in COVID-19 cases in the Brazilian city of Manaus may 
have been due to a new variant (known as P1 or ``Brazilian variant'') 
that ``may evade immunity generated in response to previous 
infections.''\8\
---------------------------------------------------------------------------
    \4\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
    \5\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
    \6\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
    \7\ https://www.cdc.gov/mmwr/volumes/70/wr/mm7008a3.htm.
    \8\ https://www.thelancet.com/article/S0140-6736(21)00183-5/
fulltext.

    Question. The South African and Brazilian variants continue to 
circulate in the United States.\9\ What is your level of concern about 
the danger that these and other COVID-19 variants may pose to nursing 
homes, particularly residents who have been most vulnerable to the 
disease?
---------------------------------------------------------------------------
    \9\ https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant-
cases.html.

    Answer. The variants pose a significant concern to both vaccine 
effectiveness and the current infection control practices. The lack of 
widespread genetic testing also makes understanding how these viruses 
are spreading in long term care and if they are more virulent difficult 
to determine. Funding to State public health laboratories is needed to 
expand genetic testing and to also evaluate residents who test positive 
after vaccination. Currently, our members routinely hear that the 
vaccines are not 100-percent effective, so we expect to see some 
residents who are fully vaccinated test positive. There is little 
evaluation being conducted to determine if these post-vaccination 
infections are the result of variants or not. Similarly, we do not know 
if PPE recommendations and source control masks are as effective with 
this new variant and if the airborne component of spread is more 
prevalent. Funding to NIH and CDC to support more rapid research is 
---------------------------------------------------------------------------
needed.

    Question. Is additional surveillance necessary to detect the spread 
of viral variants? What types of surveillance, if any, should be 
implemented in regards to the nursing home industry specifically?

    Answer. Yes, as mentioned above, more funding is needed to public 
health and research institutions to expand genetic testing and contact 
tracing of residents and staff who test positive, particularly those 
who have been fully vaccinated. CDC and CMS also need to update their 
testing surveillance guidance that takes into consideration vaccination 
status but also persistent low levels of viral shedding at non-
infectious levels causing PCR positive tests. These ``false positive'' 
PCR tests trigger changes in visitation, testing and cohorting 
procedures in nursing homes that may not be necessary. Understanding 
persistent long-term viral particle shedding is needed to understand 
how to use PCR and Antigen testing in LTC.

    Question. What steps has the industry taken to prepare itself for 
the possible need for rapidly distributing booster shots to protect 
against variants? In your view, what would be the best model to 
accomplish such a rollout, and what would be a reasonable amount of 
time?

    Answer. We are working with a coalition of LTC pharmacy providers, 
LTC provider associations and national associations representing State 
public health and immunization programs to develop a more efficient way 
to enroll LTC pharmacies and LTC providers in State immunization 
programs and registries. This would streamline the process for nursing 
homes and other long-term care facilities to offer booster shots to 
residents and staff on-site, which is a critical component of any 
vaccination effort in long-term care. AHCA/NCAL also plans to build 
upon its existing #GetVaccinated campaign (https://getvaccinated.us/) 
to educate and encourage LTC staff to get a booster shot when made 
available to them.

    One challenge is the inability of State immunization registries to 
interface effectively with CDC and other Federal databases. Funding is 
desperately needed to improve the public health infrastructure at CDC 
and State public health agencies with respect to immunization 
registries and infection disease reporting. The inability of these 
systems to share data coupled with its dated, inefficient 
infrastructure does not allow easy modifications to facilitate tracking 
during an epidemic or pandemic. This has been a significant hinderance 
and source of frustration for many during the COVID-19 pandemic. This 
can be explained by years of poor public health funding for adequate 
infrastructure. Congressional support to modernize CDC's and State 
public health databases would make a significant difference.

    Additionally, funding to help CMS build data systems to track key 
leadership positions in skilled nursing facilities (SNFs) is needed to 
get information out quickly. CMS currently lacks a data system to 
collect information from States on the SNF administrator, director of 
nursing, infection preventionist or medical director, four positions 
required by regulations. States maintain these lists but rarely in a 
readily accessible digital format and not in ways that can be easily 
shared with CMS or other Federal agencies. As a result, rapid 
communication of new information and guidance is not possible. If a 
booster shot is required, communication with these four positions will 
be critical.

    Question. What lessons can be drawn from the experience of the CVS-
Walgreen Long-Term Care Partnership?

    Answer. This partnership in many ways was an amazing success story. 
In less than 3 months, a national program was created to distribute, 
administer, and report on vaccine administration to more than 15,000 
nursing homes and 30,000 other long-term care facilities, such as 
assisted living.

    One criticism is the delegation to States, which in some ways 
helped, but mainly added confusion and overly complicated the program. 
States decided when the program would start, which vaccine to use, and 
if nursing homes should start first or simultaneously with assisted 
living and other LTC facilities. This crated scheduling challenges.

    Moreover, the lack of a database on the four professional positions 
described above required collecting primary contact information for all 
SNFs, which resulted in challenges reaching the individual if there 
were any errors or typos. This resulted in difficulties for CVS and WAG 
in contacting facilities to schedule clinics. Having an up-to-date 
database on the four leadership positions (administrator, director of 
nursing, infection preventionist and medical director) is desperately 
needed at CMS. This of course will require funding to CMS to develop 
and maintain such a database.

                                 ______
                                 
              Question Submitted by Hon. Elizabeth Warren
    Question. Private equity facilities own approximately 11 percent of 
nursing homes nationwide.\10\ For years, reports have highlighted that 
private equity owned facilities provide worse care than other nursing 
homes. According to one 2014 study, private equity-owned facilities 
generally ``deliver poorer quality of care'' than other chain-
affiliated for-profit facilities; are likely to try to reduce cost by 
``substituting expensive but skilled RNs with cheaper and less skilled 
nurses''; and ``report significantly higher number of deficiencies'' 
that climb with more years of private equity ownership.\11\ A study 
released last month similarly showed found that private equity 
ownership of nursing homes ``increases the short-term mortality of 
Medicare patients by 10 percent, implying 20,150 lives lost due to 
[private equity] ownership over [a] 12-year sample period.''\12\ 
Private equity ownership was also associated with ``declines in other 
measures of patient well-being, such as lower mobility'' and taxpayer 
spending-per-episode increases of 11 percent.\13\ Meanwhile, an 
Americans for Financial Reform analysis of long-term care facilities in 
New Jersey found higher rates of COVID-19 infection and death at PE-run 
sites.\14\ However, it is challenging to identify specific ownership 
structures of nursing homes based on existing CMS data.\15\
---------------------------------------------------------------------------
    \10\ Skilled Nursing News, ``COVID-19 Brings Private Equity 
Investment in Nursing Homes Into the Spotlight,'' Alex Spanko, March 
19, 2020, https://skillednursingnews.com/2020/03/covid-19-brings-
private-equity-investment-in-nursing-homes-into-the-spotlight/.
    \11\ Journal of Health Care Finance, ``Private equity ownership of 
nursing homes: Implications for quality, June-July 2014,'' Rohit 
Pradhan et al., October 2015, http://healthfinancejournal
.com/index.php/johcf/article/view/12.
    \12\ National Bureau of Economic Research, ``Does Private Equity 
Investment in Healthcare Benefit Patients? Evidence From Nursing 
Homes,'' Atul Gupta, Sabria T. Howell, Constantine Yannelis, and 
Abhinav Gupta, February 2021, https://www.nber.org/system/files/
working_papers/w28474/w28474.pdf.
    \13\ Id.
    \14\ Americans for Financial Reform, ``Report: The Deadly 
Combination of Private Equity and Nursing Homes During a Pandemic,'' 
August 6, 2020, https://ourfinancialsecurity.org/2020/08/report-3-
private-equity-nursing-homes-coronavirus/.
    \15\ Health Affairs, ``These Administrative Actions Would Improve 
Nursing Home Ownership and Financial Transparency in the Post COVID-19 
Period,'' Charlene Harrington et al., February 11, 2021, https://
www.healthaffairs.org/do/10.1377/hblog20210208.597573/full/.

    Answer. AHCA represents more than 14,000 member facilities, 
including both for-profit and not-for-profit nursing homes and assisted 
living facilities. How many of these facilities are nursing homes? What 
percentage of these facilities are owned or controlled by private 
equity entities? For all nursing homes, what is the average percentage 
of nursing home revenue that is spent on direct patient care? For the 
private equity-owned or controlled facilities, what is the average 
percentage of nursing home revenue that is spent on direct patient 
---------------------------------------------------------------------------
care?

    AHCA membership includes approximately 10,000 of the Nation's 
15,000 nursing homes, 4,000 of the estimated 30,000 assisted living 
communities, and 200 intermediate care facilities for individuals with 
intellectual and development disabilities (ICF/ID). Among nursing 
homes, we represent approximately two-thirds of for-profit facilities, 
half of not-for-profit facilities, and half of government facilities. 
We do not have information nor access to CMS PECOS data on number owned 
or controlled by private equity. We also do not collect or calculate 
the proportion of revenue spent on direct patient care.

                                 ______
                                 
             Questions Submitted by Hon. Patrick J. Toomey
    Question. Prior to the COVID-19 pandemic, I worked alongside my 
Pennsylvania colleague Senator Casey to address the quality of care for 
nursing homes residents. We were successful in pressing the Centers for 
Medicare and Medicaid Services (CMS) to publicize both participants and 
candidates affiliated with the Special Focus Facility (SFF) program, 
which provides more frequent oversight of facilities that consistently 
fail to meet Federal safety and care requirements.

    Specific to this issue, Senator Casey and I reintroduced the 
Nursing Home Reform Modernization Act (S. 782) on March 16, 2021, which 
would expand the SFF program to ensure that all facilities nominated as 
candidates for the program receive additional oversight. Our 
legislation would also increase educational resources for 
underperforming facilities and create an independent advisory panel to 
inform CMS on how best to rank nursing home performance.

    As you know, part of our bill would allow nursing homes to reinvest 
their civil monetary penalties (CMP) to make improvements and remedy 
the root causes contributing to consistent deficiencies. Financial 
penalties can be an effective tool to incentivize compliance with 
Federal requirements. However, if the ultimate goal is to help a 
facility improve and keep residents in their homes--at what point do 
the penalties make it more challenging for a consistently poor 
performing nursing home to improve?

    Answer. By the time a SNF finds itself on the Special Focus 
Facility list, it has often had repeated citations but also CMPs over 
the preceding two to 3 years. At this point, further citations and CMPs 
are very unlikely to remedy the underlying problem. Also, at this 
point, the facility needs to invest in additional resources which may 
be staff, equipment, or environmental changes. Further citations and 
CMPs would no longer be helpful at this point and would only make 
matters worse. Having access to capital, like the money collected 
through CMPs would remedy the situation by helping these facilities 
acquire the resources needed to address underlying issues. The Care For 
Our Seniors Act, a package of major reforms for the nursing home 
industry we developed with LeadingAge, includes a proposal on how to 
address chronic poor performing nursing homes (https://
www.ahcancal.org/Advocacy/Documents/Poor-Performing-Facilities.pdf).

    Question. Can you describe a situation in which a poor-performing 
nursing home and its residents would benefit from the facility being 
able to reinvest its CMPs into quality improvement initiatives?

    Answer. Facilities often find themselves on the SFF list due to 
lack of staffing, equipment or outdated physical environment. Rural 
facilities especially often need access to clinical expertise that is 
not available, and the cost to upgrade to broad band Internet and offer 
telemedicine are not possible without access to additional funds. This 
is where access to the CMP funds would be helpful. Additionally, 
chronically poor-performing facilities may need help addressing low 
staffing levels, and CMPs funds could assist in recruiting caregivers 
and offering them signing bonuses. Fundamentally, taking more resources 
away from an already under resourced facility for whatever the reasons 
does not make sense. Providing access to CMP funds or allowing further 
CMPs to be used to reinvest in needed changes to remedy the root cause 
leading to the chronic poor performance would help avoid closure of 
these facilities.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. Wyoming nursing facilities are mostly located in rural 
and frontier communities. These nursing homes are often attached to a 
rural hospital. These facilities provide training for Certified Nursing 
Assistants (CNAs), which are the backbone of the nursing home 
workforce. Through the years, nursing homes in my State have reported 
they have lost the ability to train their own CNAs. According to an 
article published in Health Affairs, this is because nursing homes with 
a civil monetary penalty greater than $10,000 lose the ability to 
conduct CNA training for 2 years. In rural communities, where the 
nursing home is often the sole source of training for CNAs, this 
creates a tremendous burden.

    Please comment on the impact losing the ability to train CNAs has 
on nursing homes.

    Answer. Finding and recruiting staffing at all levels but 
particularly among CNAs has become a greater and greater challenge. 
Developing a training program has been an effective strategy to recruit 
and retain CNAs. These programs require an investment in resources and 
staff. However, current statutory language requires these training 
programs to be suspended for 2 years for any citation resulting in 
substandard quality or CMPs greater than $10,000. Even when the 
facility has quickly remedied the situation leading to the CMP so that 
they are in full compliance, the CNA program is suspended for 2 years. 
This has not only resulted in the closure of many programs but also 
inhibits many providers from investing in the creation of these 
programs for fear of suspension. Once suspended, the ability to recruit 
and train additional staff becomes even more challenging. Often more 
staff are needed, yet the solution to the problem is hindered by this 
statutory language.

    Question. Can you provide suggestions on how to address this 
situation, especially in rural communities?

    Answer. It is understandable that a facility found to be seriously 
out of compliance with Medicare or Medicaid standards should not be 
training CNAs, but once the facility has remedied the situation and 
attained substantial compliance, the suspension of the CNA program 
should be lifted. This requires a change to the statute, which AHCA has 
advocated for over the past several years. We would be happy to work 
with your office and the Senate Finance Committee to address this 
problem.

    Question. A top concern of Wyoming nursing facilities is making 
sure there are enough staff to care for residents. Many Wyoming nursing 
homes provide professional development and other educational 
opportunities to attract and maintain their staff.

    Can you discuss solutions related to workforce development you 
believe will improve the ability of nursing facilities to attract and 
maintain direct care staff?

    Answer. There are two principal challenges with recruiting and 
retaining staff in nursing homes. First, there are not enough nurses 
and other health professionals being trained in the Nation to meet the 
needs of older adults seeking care from all types of providers, 
including hospitals, physician offices, home health agencies, etc. 
Second, hospitals and other provider settings are able to offer more 
competitive wages and benefits as they are less dependent on Medicaid 
funds. In SNFs, two-thirds of the residents are covered by Medicaid, 
which MedPAC has shown under reimburses for the actual cost of care in 
nursing homes. As a result, nursing homes cannot compete with hospitals 
for nurses and other staff.

    What is desperately needed is for Congress to provide additional 
funding to nursing schools and other schools training our health-care 
workforce but to make the funding tied to having graduates work in 
long-term care. This is similar to funding to medical schools linked to 
training primary care providers. Without this requirement, we have seen 
new graduates seek employment in hospitals and other provider settings. 
Another approach is to provide financial incentives to health-care 
professionals to work in long-term care. Two mechanisms would include 
loan forgiveness and tax incentives. Many graduates including nurses, 
pharmacists, therapists and social workers graduate with enormous 
student debt. Having loan forgiveness for each year working in long-
term care would help increase the workforce in nursing homes. 
Similarly, tax credits to health-care professionals who work in long-
term care would also help.

    There are other strategies we are happy to discuss with you and 
your staff but these two approaches we believe are most effective. You 
may also view more of our ideas to address workforce challenges in 
long-term care through our specific proposal in our Care for Our 
Seniors Act, a package of major reforms for the nursing home industry 
we developed with LeadingAge (https://www.ahcancal.org/Advocacy/
Documents/Workforce-Strategies.pdf).

    Question. An article in the March edition of Health Affairs points 
out that although staff turnover is an important indicator of nursing 
home quality, this has never been included on the Nursing Home Compare 
website, maintained by Medicare.

    Please discuss the impact of staffing turnover on the quality of 
care provided in nursing homes.

    Answer. Staff turnover has been shown to be associated with quality 
outcomes in numerous academic studies. In fact, turnover has a stronger 
association with quality outcomes than staffing levels. When staff 
leave, it's hard to assure consistent compliance with policies and 
procedures as you are always training new staff. Also, new staff are 
less familiar with the residents and therefore, may miss subtle changes 
in their condition that signify a problem. We have made staff turnover 
and retention a center piece of the AHCA Quality Initiative but were 
hampered by the lack of a Federal measure on turnover and retention.

    Question. Specifically, do you believe turnover rates from nursing 
homes should be made more readily available for public review?

    Answer. Yes, AHCA has supported CMS moving to calculate and 
publicly report staff turnover and retention. AHCA made turnover and 
retention a core measure and goal of our Quality Initiative. We 
believe, as the literature has shown, that turnover and retention are 
more important measures than staffing levels.

                 Questions Submitted by Hon. Todd Young
    Question. Workforce issues, including high staff turnover, have 
been a longstanding issue for nursing homes. Research suggests that 
high nursing staff turnover can have a negative impact on the quality 
of care for residents; it has been connected with increases in patient 
rehospitalizations and the use of physical restraints, and it can also 
affect the spread of infections within nursing homes.

    The COVID-19 pandemic has only exacerbated this problem. Nursing 
homes lost nearly 10 percent of their workforce in 2020. And a 
significant percentage of nursing homes nationwide--including nearly 16 
percent in my State of Indiana--are still reporting shortages of 
nursing staff.

    Dr. Gifford, one of AHCA/NCAL's recommendations to governors early 
on in the pandemic was to temporarily waive existing State regulations 
and allow medical professionals to work across State lines. Are these 
State licensing barriers something that could be streamlined or 
otherwise addressed on a more permanent basis to respond to workforce 
issues in nursing homes?

    Answer. State licensing laws for physicians, nurses, 
administrators, pharmacists, and other health-care professionals are 
similar in concept but differ in specific details. This makes it 
difficult for professionals moving from State to State. CMS used the 
public health emergency to issue 1135 waivers allowing health-care 
professionals who bill for and work in Medicare-certified facilities in 
any State as long as they were licensed in good standing in one State. 
However, this does not supersede State licensing requirements. During 
emergencies such as a pandemic, natural disaster, etc. this limits the 
ability of health-care professionals to cross State lines to help when 
workforce shortages exist relative to the emergency.

    Two potential solutions exist. First, each State as part of their 
emergency preparedness plans should have model executive orders for 
governors to waive State licensing restrictions to allow health care 
professionals from other States to assist during the emergency. While 
this need arises during nearly every emergency, such model orders are 
not part of each State's emergency preparedness plans. Second, States 
can participate in ``compact'' agreements that allow the easy 
transition between States for individuals with licensure in good 
standing. This may require State legislation to participate. Many 
States have such agreements for nurses and physicians but not all.

    Without such, States are reinventing the wheel to develop executive 
orders and rushing to their State legislatures to get approval during 
each emergency. This is not something that States should be waiting 
until an emergency happens before addressing.

    Question. How can the Federal Government better support 
partnerships between nursing homes and academic entities whose 
graduates may be interested in joining the long-term care workforce?

    Answer. The Federal Government can emphasize the need for more 
State cooperation in allowing health-care professionals with licensure 
of good standing to move between States, particularly during 
emergencies. Congress should link Federal emergency planning funding 
and other Federal funding to making sure States have these programs in 
place before emergencies happen.

    Question. As outlined in many of your testimonies, the visiting 
restrictions and isolation necessitated by the COVID-19 pandemic took a 
heavy toll on the emotional and mental health of many nursing home 
residents separated from their family members and other loved ones. 
Fortunately, with increased vaccination and declining COVID-19 deaths, 
many of these restrictions have been lifted.

    While we hope that restrictions of this scale will not be necessary 
again, it is worth examining ways to alleviate the negative emotional 
and mental health effects that isolation may have on nursing home 
residents. The use of technology, for one, has allowed residents to 
interact virtually with family and other loved ones from whom they are 
otherwise separated. Expanded use of telehealth has also helped 
residents access routine health-care services while limiting spread of 
the coronavirus.

    What are some lessons learned from the public health emergency in 
terms of the integration of technology in nursing homes--both in 
helping residents visit virtually with loved ones and in accessing 
health-care services?

    Answer. Video-conferencing in nursing homes is a technology that we 
need to build upon and expand. Prior to the pandemic, communication 
with family and friends was challenging. In-person visitation often 
only happened when family or friends lived close by and could travel. 
Anecdotally, we hear that nearly half of residents never have in-person 
visits due to family or friends living far away or their inability to 
travel to the facility. The pandemic exposed this limitation when all 
visitors were restricted.

    The restriction of all visitors required the use of digital and 
video technology which often does not exist in many long-term care 
facilities due either to inadequate Internet infrastructure as well as 
technological devices to support video conferencing. As a result, many 
staff turned to their personal smart phones or tablets to help family 
communicate with residents. CMS did allow facilities to apply for a 
limited amount of funds from the CMP accounts to purchase equipment to 
facilitate video conferencing. While this was helpful, it was woefully 
inadequate and took substantial time to complete the application and 
review process.

    The use of telemedicine was critical during the pandemic. The risk 
of spread of the virus increased with each human-to-human interaction. 
Use of telemedicine allowed health-care professionals to provide care 
to residents without being physically present. This was facilitated by 
CMS waiving Medicare payment regulations through 1135 waivers; however, 
these waivers will cease when the public health emergency expires. 
There are benefits to telemedicine for patients even after the 
pandemic. Bills such as S. 368, the Telehealth Modernization Act, led 
by Senator Scott, would make those waivers permanent, and we support 
this legislation.

    Question. Do you anticipate this type of technology continuing to 
be used beyond the pandemic?

    Answer. Yes, I do. As mentioned, in-person visitation was often a 
challenge prior to the COVID. The need for better and more frequent 
communication between family members and friends is needed. The 
familiarity and expansion in its use will likely continue after the 
pandemic but will require building the appropriate infrastructure.

    Many rural facilities have inadequate access to broadband Internet 
to facilitate video conferencing. Communication at popular times of the 
year, such as holidays, often overwhelms a facility's bandwidth. 
Additionally, telemedicine can help provide life-improving care to 
residents, especially in rural communities, where the availability of 
health-care professionals is scarce. Telemedicine could help fill the 
gap where workforce shortages exist. Also, the technology is 
continually evolving and improving, and nursing homes do not always 
have the resources to keep up with the latest technology even though it 
could be beneficial to residents.

    Congress should fund the expansion of Internet infrastructure 
(bandwidth and Wi-Fi technology) to allow strengthen communication 
between residents and their families and friends as well as further 
develop telemedicine. The constant upgrading necessary to keep abreast 
of the latest technology will also be critical to better patient care, 
avoid problems over time, and prepare for the next emergency.

                                 ______
                                 
               Questions Submitted by Hon. Maggie Hassan
    Question. We have heard repeatedly from long-term care facility 
workers that the lack of access to paid sick leave is keeping some 
individuals from choosing to take the COVID-19 vaccine. Widespread 
vaccinations within long-term care facilities is our most effective 
tool in protecting workers and residents, so we must eliminate any 
barriers that are impacting vaccine uptake at this critical time.

    Approximately what percentage of your member facilities currently 
provide paid sick leave to workers?

    Answer. We do not have that information available among our 
membership.

    Question. Among those workers who receive paid sick leave, how many 
hours does each worker receive annually?

    Answer. We do not have that information available among our 
membership.

    Question. What additional paid sick leave policies have your member 
organizations established for workers since the beginning of the COVID-
19 pandemic?

    Answer. Anecdotally, we have heard many providers provided various 
additional wages and benefits to staff including ``hero'' or bonus pay, 
childcare, assistance programs for things like groceries, and paid time 
off, whether to receive the vaccine or if they had to isolate due to 
symptoms of or exposure to COVID.

    Question. What additional paid sick leave policies have your member 
organizations established for workers the relationship between access 
to paid leave and COVID-19 vaccination rates became apparent?

    Answer. As mentioned above, we have heard anecdotally that 
providers provided paid time off to staff to receive the COVID-19 
vaccine if they were unable to attend one of the three on-site clinics 
offered at the facility by CVS or Walgreens. Similarly, we heard they 
offered paid time off should they develop any symptoms following the 
vaccine that limited their ability to work.

    Question. In addition to being an important near-term protection 
during the COVID-19 pandemic, do you believe that widespread access to 
annual paid sick leave for workers in long-term care facilities would 
reduce the prevalence of influenza and other illnesses that pose risks 
to residents in these facilities?

    Answer. AHCA does not have information on paid sick leave for our 
members. Health insurance and paid sick leave are important for all 
workers in the country including health-care workers but are not always 
consistently offered to employees. Efforts to provide paid sick leave 
should also be coupled with increase childcare services for long-term 
care health-care workers. These would help with control of infectious 
outbreaks, epidemics and pandemics. We would support efforts by 
Congress to make these services available and affordable to health-care 
workers and other staff who provide vital services in nursing homes.

    It is important to keep in mind that all health-care settings, 
especially long-term care, must delicately balance ensuring that there 
are enough caregivers to properly aide residents and patients, while 
also making sure sick employees do not create unnecessary, additional 
risks to residents. This means we need additional support to help 
prevent workforce shortages and that long term care receives the 
necessary resources to further invest in their staff.

    We have been calling for help with the long-term care workforce 
shortage and chronic underfunding of nursing homes for years. If 
policy-makers wish to expand paid sick leave or other benefits to 
health-care workers, we also need your support in funding such benefits 
and in recruiting more caregivers to long-term care. Our Care for Our 
Seniors Act (www.ahcancal.org/solutions) offers meaningful proposals to 
address workforce and funding challenges that could help encourage more 
providers to offer or expand pick sick leave benefits.

                Questions Submitted by Hon. John Cornyn
    Question. We've heard from nursing homes and long-term care 
facilities that experienced difficulty staying up to date with public 
health guidance as they were released. You've noted the challenge of 
guidance being outdated by the time they were released.

    Did AHCA members experience issues with guidance coming from State 
and local public health officials conflicting with CDC and CMS 
guidance? What recommendations do you have to improve the process of 
new guidance being pushed out to congregate care providers?

    Answer. While CMS and CDC worked at unprecedent pace to issue new 
guidance, it was still often slow and outdated by the time it was 
issued, often due to this being a novel coronavirus. In some 
circumstances, the clearance process delayed issuing of guidance 
further. Notice that Federal guidance was forthcoming was not 
consistently shared or was misstated due to clearance delays that took 
longer than anticipated. As a result, States stepped in to develop 
their own guidance which invariably would conflict with Federal 
guidance when issued and/or conflict with other States' guidance. This 
added to confusion among providers.

    The linking of guidance to strict enforcement actions also 
exacerbated the challenges. Facilities using a ``good faith'' effort to 
follow guidance would find themselves being cited for non-compliance. 
This led providers to ask for detailed guidance for every scenario, 
which further bogged down the Federal agencies. Further complicating 
the confusion was the fact that the multitude of guidance was located 
on multiple different webpages and issued by numerous agencies. Also, 
early on changes to guidance documents and webpages were made without 
any notation, making it hard to locate changes and ensure providers 
were accessing the most updated version. CDC eventually added a date 
indicating when the webpage was last updated and provides a short 
summary of the changes made at the top of the page. This has been 
extremely helpful.

    Guidance is needed from the Federal agencies. It needs to be issued 
quickly and located in a centralized location--ideally on single page 
encompassing guidance from all relevant agencies. Notations need to be 
made on any changes being made to existing guidance that is updated. 
CMS continues to issue its guidance in QSO memos, and one cannot find a 
single page pulling together all the guidance in one place.

    Strict enforcement needs to be limited to those who are blatantly 
non-compliant. Those who are aware of the guidance and making a good 
faith effort to comply but may be doing not as intended should not be 
cited, fined, or sued.

    Question. AHCA called for reforms to Medicaid reimbursement to 
adequately fund care in nursing homes. Can you elaborate on what steps 
you believe are necessary to improve care for residents?

    Answer. For years, nursing homes have been underfunded by Medicaid, 
significantly impacting their ability to invest in their workforce, 
clinical practices, and infrastructure. COVID-19 exacerbated these 
financial challenges, as the industry has dedicated tens of billions of 
dollars to fight the virus with PPE, testing and additional staff 
support. This pandemic has pushed nursing homes to the financial brink, 
and more than 1,000 facilities are in danger of closing this year, 
threatening access to long-term care for vulnerable seniors and 
individuals with disabilities. With 60 percent of residents relying on 
Medicaid for their daily care, the program must fund nursing homes for 
the actual cost it takes to provide high-quality care.

    To address chronic Medicaid underfunding, AHCA and LeadingAge 
propose the following short and long-term investment strategies for 
nursing homes through our Care for Our Seniors Act (www.ahcancal.org/
solutions):

      Enhanced FMAP (EFMAP) to States to for the mandatory nursing 
facility benefit with requirements that additional Federal funds be 
used for nursing facility (NF) rates. Additions to NF rates will cover 
the costs of new quality and clinical provisions to improve patient 
care and staff safety;

      Federal Framework for ``Allowable Cost'' or ``Reasonable Cost'' 
would establish Federal guidelines for State allowable cost 
definitions. Currently, State definitions of ``allowable cost'' vary 
widely and, without a Federal framework, will continue to limit 
Medicaid reimbursable care and other nursing facility costs. 
Specifically, AHCA would require States to cover 100 percent of costs 
up to the 90th percentile; and

      Medicaid Rate Adequacy Requirement that rates are brought up to 
the cost of care and, subsequently updated regularly to keep pace with 
increases in costs of care. Currently, Medicaid contains no requirement 
that Medicaid rates be updated to keep pace with increases in the cost 
or care, ensuring quality or administrative burden. Under AHCA's 
proposed policy, States would undertake a two-step process: (1) conduct 
a cost of care study comparing market costs and reimbursement with 
Medicaid reimbursement levels and increase reimbursement to the new 
``allowable cost'' benchmark; and (2) conduct a Medicaid rate update 
and rebase annually replicating step one, above.

    Additionally, AHCA proposes that States be required to form a 
Nursing Facility Value-Based Purchasing (VBP) Committee. State Nursing 
Facility VBP Committees would be charged with developing a State-
specific Nursing Facility VBP Design Concept which must be submitted to 
CMS 2 years after the end of the Public Health Emergency.

                                 ______
                                 
               Questions Submitted by Hon. James Lankford
    Question. There has been heightened discussion about the nursing 
home survey process regarding what it accomplishes and perhaps what it 
misses.

    What is your opinion on the current process, and what do you think 
can be done to ensure better resident care?

    Answer. The current nursing home survey process is not serving 
residents' best interests. The goal of the nursing home survey process 
is to assure basic levels of quality and safety for all patients, 
residents and clients receiving care from Medicare and Medicaid 
certified providers. However, the same modes of citation and penalty 
have been used for decades and have not evolved to reflect the science 
of quality improvement nor a current understanding of how to 
effectively use oversight to create change and achieve desired 
outcomes. The punitive nature of the process continues to drive good 
staff members and leaders out of long-term care and into other health-
care jobs where the oversight process focuses on supporting a culture 
of safety and continuous quality improvement. Multiple stakeholders--
including nursing home staff, consumer advocates, Congress, and CMS--
are dissatisfied with the survey and enforcement process and results.

    For instance, the same top issues are cited year after year, which 
shows that the current oversight process is not successfully driving 
improvements in these areas as it is meant to do. At the same time, 
with more than 200 distinct citations or ``F-tags'' that may be issued, 
half are cited less than 1 percent of the time. This shows the survey 
process is trying to measure too many things and is not focused on the 
most important areas impacting resident care.

    In addition, the current survey process does not effectively 
identify providers' systemic strengths and weaknesses, nor are these 
strengths and weaknesses communicated clearly and effectively to 
consumers. The survey and enforcement process centers around inspection 
and control which is not driving improved results for quality of care 
and quality of life for residents. The impact and success of the 
survey/regulatory system is frequently measured by rates of penalties 
imposed and performing more frequent surveys, rather than by the 
quality improvements that have been achieved and sustained through the 
oversight process. This approach makes it difficult for providers to 
correct problems and sustain compliance while preventing consumers from 
making more informed choices that also help drive quality improvement.

    Within this system, CMS spends much of its survey budget on 
addressing poor performing nursing homes, yet the current process and 
use of resources is not effective in improving care among struggling 
providers. At the same time, too much time is spent on surveying 
providers that are consistently high performers. The extensive 
investment of time, money and energy by State survey agencies, the 
Federal Government, nursing home staff as well as other stakeholders in 
the survey process is not delivering an equal or better return on 
investment to benefit the residents the system is intended to serve.

    The goal of the survey process should be to get as many providers 
to be in substantial compliance all the time. AHCA recommends a more 
modern, efficient, and effective survey process that focuses on what 
matters most to residents to support high quality of care and quality 
of life. This includes reforming the survey process based on 
understanding when citation and enforcement is helpful in driving 
compliance andimprovement and when it is important to recognize and 
support providers' good faith efforts; implementing changes to better 
help turn around chronic poor performing nursing homes; and adding 
customer satisfaction to the Five-Star rating system to help monitor 
the quality of a facility for family members and guidance consumer 
choice.

    AHCA and LeadingAge's Care for Our Seniors Act outlines these 
proposed reforms to the oversight system (www.ahcancal.org/solutions).

    Question. Do you think that adding customer satisfaction 
information to the ``nursing home compare'' website may be helpful in 
providing accountability?

    Answer. Yes, customer satisfaction should be added to Nursing Home 
Compare. Customer satisfaction is well-excepted and a critical type of 
quality measure. Nursing homes are the only Medicare provider that does 
not have customer satisfaction collected and publicly reported by CMS. 
During the pandemic, we have heard of the importance of communication 
with family and residents about what is happening. We believe one way 
to examine how facilities responded would have been to collect 
satisfaction data but unfortunately, despite our repeated calls for 
this information to be collected and reported, this has not happened.

    AHCA and LeadingAge included adding customer satisfaction to 
Nursing Home Compare among our many reform proposals in the Care for 
Our Seniors Act (https://www.ahcancal.org/Advocacy/Documents/Customer-
Satisfaction.pdf).

                                 ______
                                 
Prepared Statement of R. Tamara Konetzka, Ph.D., Louis Block Professor, 
  Department of Public Health Sciences, Biological Sciences Division, 
                         University of Chicago
    Chairman Wyden, Ranking Member Crapo, and distinguished members of 
the committee, thank you for the opportunity to testify today on the 
topic of COVID-19 in nursing homes.

    My name is Tamara Konetzka. I am a professor of health economics 
and health services research at the University of Chicago. I have been 
conducting research on long-term and post-acute care for more than 25 
years. I have led numerous studies that examine the quality of nursing 
home care and how public policy might improve it, how Medicare and 
Medicaid policy influence care access and quality, and how increasing 
provision of services in home- and community-based settings impacts 
health. I serve on the technical expert panel that advises the Centers 
for Medicare and Medicaid Services on the Nursing Home Compare 5-star 
rating system that publicly reports nursing home quality.

    Almost 40 percent of all COVID-19 deaths in the United States have 
been linked to long-term care facilities.\1\ The scope of this problem 
became apparent early in the pandemic, generating widespread media 
attention and public alarm. Almost a year ago, a New York Times article 
referred to nursing homes as ``death pits,''\2\ due to seemingly 
uncontrollable COVID-19 spread within these facilities. This 
devastation continued during subsequent surges.\3\
---------------------------------------------------------------------------
    \1\ About 40 percent of U.S. Coronavirus Deaths Are Linked to 
Nursing Homes. The New York Times. 2020.
    \2\ Stockman F., Richtel M., Ivory D., Smith M. ``They're Death 
Pits'': Virus Claims at Least 7,000 Lives in U.S. Nursing Homes. New 
York Times. April 17, 2020.
    \3\ Konetzka R.T., Gorges R.J. Nothing Much Has Changed: COVID-19 
Nursing Home Cases and Deaths Follow Fall Surges. J Am Geriatr Soc. 
2020.

    The circumstances that led to this tragedy, often referred to as a 
``perfect storm,''\4\ start with the attributes of the novel 
coronavirus itself. The coronavirus that causes COVID-19 is airborne, 
can be spread asymptomatically, and is particularly dangerous for older 
adults with underlying health conditions. It is therefore no surprise 
that nursing home residents, with their demographic and clinical 
profile, suffered disproportionately high rates of cases, 
hospitalizations, and deaths.
---------------------------------------------------------------------------
    \4\ Ouslander J.G., Grabowski D.C. COVID-19 in Nursing Homes: 
Calming the Perfect Storm. J Am Geriatr Soc. 2020.

    The nursing home setting exacerbates this risk. Many facilities 
house, in close quarters, dozens or sometimes hundreds of residents who 
require hours of hands-on care on a daily basis. Many residents share 
rooms with others. Physical distancing is extremely difficult given the 
realities of congregate care settings. Finally, asymptomatic spread 
means that residents and staff can cause an outbreak without knowing 
it. This was especially lethal early in the pandemic when there was 
less known about asymptomatic transmission and less widespread testing 
---------------------------------------------------------------------------
of asymptomatic individuals.

    At long last, there is cause for optimism. Overall COVID-19 cases 
and deaths have declined nationwide in recent months.

    The sharpest declines are occurring in nursing homes. The weekly 
number of new COVID-19 cases and deaths in nursing homes are at their 
lowest since national data collection began last May. Reported deaths 
among nursing home residents have declined by more than 80 percent 
since the new year. It is still difficult at this early date, and 
without the necessary data, to rigorously assess the causes of the 
decline.

    We do know that the vast majority of nursing home residents have 
been vaccinated. This has almost certainly played a large role. Trends 
in nursing home cases and deaths, after closely matching trends in 
community cases and deaths throughout the pandemic, started to diverge 
mid-January, when a much higher percent of nursing home residents had 
been vaccinated than community residents.

[GRAPHIC] [TIFF OMITTED] T1721.027


    .epsIncreased vaccination and declining COVID-19 deaths have 
brought other physical and emotional benefits for nursing home 
residents. These made possible new CDC/CMS recommendations that nursing 
homes fully open to visitors, a hugely important development for 
residents and their families.

    Despite this welcome progress, there remains need for caution, and 
particularly the need to resist complacency. First, not all residents 
and staff are vaccinated. Whereas most nursing home residents were 
eager to be vaccinated, take-up has been much lower among staff, by 
some reports 37 percent.\5\ Second, many facilities face high staff and 
resident turnover. This dynamic will produce declining vaccination 
rates in many facilities over time without ongoing efforts. Third, 
COVID-19 infection is still possible after vaccination, a risk that may 
increase with new coronavirus variants. If the U.S. experiences a new 
surge in cases this spring as public health measures are relaxed, it 
will provide a real test of the effectiveness of vaccination efforts in 
nursing homes in avoiding the new surge.
---------------------------------------------------------------------------
    \5\ Gharpure R., Guo A., Bishnoi C.K., et al. Early COVID-19 First-
Dose Vaccination Coverage Among Residents and Staff Members of Skilled 
Nursing Facilities Participating in the Pharmacy Partnership for Long-
Term Care Program--United States, December 2020-January 2021. MMWR Morb 
Mortal Wkly Rep. 2021;70(5):178-182.

    Even if vaccination proves to be wildly successful, there is still 
much to be learned from this pandemic to help prepare for the next one.
        evidence on predictors of nursing home cases and deaths
    Policy-makers and researchers alike have examined attributes of 
nursing homes associated with better and worse outcomes from the 
pandemic, looking for clues as to organizational best practices, 
opportunities for intervention, and where to assess blame. The results 
are clear and consistent, and not what many expected. A large body of 
evidence, some produced by our team at the University of Chicago \6\ 
and some by others, shows that the two strongest and most consistent 
predictors of worse COVID-19 outcomes are nursing home size, with 
larger facilities being more at risk, and COVID-19 prevalence in the 
surrounding community. Given an outbreak, nursing homes in the highest 
quintile of community prevalence averaged five more deaths per facility 
than similar nursing homes in the lowest quintile.
---------------------------------------------------------------------------
    \6\ Rebecca J. Gorges was my collaborator on this research. I also 
thank Xiaoxuan (Stephen) Yang for research assistance.

    Related studies examined the role of staff in inadvertently 
bringing the virus into nursing homes. One analysis used cell phone 
data to track staff movements in and out of facilities \7\ and another 
examined the ZIP codes where nursing home staff live;\8\ they found 
that staff traffic between facilities and in and out of areas with high 
virus prevalence was associated with more cases and deaths in the 
nursing homes where they worked. Nursing assistants in nursing homes 
usually work for minimum wage, few or no benefits, and no sick leave. 
To make ends meet, they often work multiple jobs in multiple 
facilities.\9\, \10\ Without sick leave, staff may have felt 
compelled to work even when symptomatic or after a COVID-19 exposure. 
These conditions likely exacerbated the risk of outbreaks.
---------------------------------------------------------------------------
    \7\ Chen M.K., Chevalier J.A., Long E.F. Nursing home staff 
networks and COVID-19. Proc Natl Acad Sci U S A. 2021;118(1).
    \8\ Shen K. Relationship between nursing home COVID-19 outbreaks 
and staff neighborhood characteristics. medRxiv preprint. 2020.
    \9\ Baughman R.A., Stanley B., Smith K.E. Second Job Holding Among 
Direct Care Workers and Nurses: Implications for COVID-19 Transmission 
in Long-Term Care. Med Care Res Rev. 2020:1077558720974129.
    \10\ Van Houtven C.H., DePasquale N., Coe N.B. Essential Long-Term 
Care Workers Commonly Hold Second Jobs and Double- or Triple-Duty 
Caregiving Roles. J Am Geriatr Soc. 2020;68(8):1657-1660.

    Equally important are nursing home attributes that are not linked 
with COVID-19 outcomes. Multiple rigorous studies have found no 
meaningful association between COVID-19 outcomes and standard nursing 
home quality metrics--usually measured by the Nursing Home Compare star 
ratings.\11\-\14\ (Studies that did find an association 
often failed to control for community virus prevalence or had very 
small samples.) Beyond the star ratings, several studies examined 
specific and salient aspects of quality such as prior infection control 
citations. Perhaps surprisingly, these were also not associated with 
poor COVID-19 outcomes.\11\, \15\
---------------------------------------------------------------------------
    \11\ Abrams H.R., Loomer L., Gandhi A., Grabowski D.C. 
Characteristics of U.S. Nursing Homes With COVID-19 Cases. J Am Geriatr 
Soc. 2020.
    \12\ Chatterjee P., Kelly S., Qi M., Werner R.M. Characteristics 
and Quality of U.S. Nursing Homes Reporting Cases of Coronavirus 
Disease 2019 (COVID-19). JAMA Network Open. 2020;3(7):e2016930.
    \13\ Dean A., Venkataramani A., Kimmel S. Mortality Rates From 
COVID-19 Are Lower In Unionized Nursing Homes. Health Aff (Millwood). 
2020;39(11):1993-2001.
    \14\ Gorges R.J., Konetzka R.T. Staffing Levels and COVID-19 Cases 
and Outbreaks in U.S. Nursing Homes. J Am Geriatr Soc. 2020.
    \15\ White E.M., Kosar C.M., Feifer R.A., et al. Variation in SARS-
CoV-2 Prevalence in U.S. Skilled Nursing Facilities. J Am Geriatr Soc. 
2020.

    Such results do not imply that we should ignore traditional nursing 
home quality and infection control measures. Rather, they suggest that 
high quality and good infection control are not enough. The reality is 
that staff enter and leave daily. When COVID-19 is prevalent in 
surrounding communities, even nursing homes that are of high quality 
and that implement recommended infection control procedures remain at 
---------------------------------------------------------------------------
risk.

    The numbers bear this out. At this point, more than 99 percent of 
nursing homes in the Nation have had at least one COVID-19 case among 
residents or staff. More than 80 percent have had at least one COVID-19 
death. This is not a ``bad apples'' problem, and no subset of nursing 
homes has found a magic bullet to keep the virus out. Despite the 
emergence of best practices and regulatory inspections for infection 
control, nursing home cases and deaths closely matched trends in 
community cases and deaths not only in spring but throughout the summer 
and fall surges.

    This reality underscores a key oversight and lesson of the past 
year. Many of us have been asking: What should nursing homes be doing 
differently? How can they do better? Alongside these questions, we must 
ask with equal urgency: What should our entire communities be doing? 
Put differently: The single most important thing we could have done as 
a Nation to reduce the tragedy in nursing homes over the past year was 
to use public health measures to control the spread of the virus in the 
general population. That will be true this coming year, as well.
          racial disparities in nursing home cases and deaths
    It is now well-known that the pandemic has disproportionately 
harmed communities of color. Disparities in COVID-19 cases and deaths 
are also clear in the nursing home sector. We recently examined these 
differences in nursing homes nationwide, in a study published in JAMA 
Network Open.\16\ Because we lacked individual-level data, we focused 
on the racial distribution of residents in each facility, categorizing 
nursing homes by the percent of residents who are white. The 
differences are striking: Nursing homes serving more (>40 percent) non-
white residents experienced more than three times as many COVID-19 
cases and deaths as those serving primarily white residents.
---------------------------------------------------------------------------
    \16\ Gorges R.J., Konetzka R.T. Factors Associated With Racial 
Differences in Deaths Among Nursing Home Residents With COVID-19 
Infection in the U.S. JAMA Netwrk Open. 2021;4(2):e2037431.

    In unpacking the reasons for such disparities, we found that race 
was correlated with two strong predictors of COVID-19 outcomes, nursing 
home size and COVID-19 prevalence in the surrounding community. Non-
white residents are more likely to live in larger facilities in 
neighborhoods where COVID-19 is prevalent. They face correspondingly 
greater risk of becoming infected or dying from COVID-19. Of note, 
although non-white residents tend to be in lower-quality nursing homes, 
these quality differences do not appear to explain disparities in 
COVID-19 outcomes, consistent with the broader research I described 
above. And although our measures of facility case-mix were limited, 
facility differences in residents' prior underlying health do not 
---------------------------------------------------------------------------
appear to explain COVID disparities, either.

    As we consider ways to reduce risk and improve outcomes for COVID-
19 and for future public health threats, reducing these disparities by 
race should be a prominent goal.
                       the importance of staffing
    The key predictors of nursing home cases and deaths--size and 
location--leave little room for immediate and direct intervention by 
nursing homes themselves. Our team took a nuanced look at the role of 
staffing using national data, in the hope of identifying factors that 
might be more under the control of nursing homes and more amenable to 
policy changes. Other researchers have found complementary results in 
smaller studies.\17\, \18\
---------------------------------------------------------------------------
    \17\ Figueroa J.F., Wadhera R.K., Papanicolas I., et al. 
Association of Nursing Home Ratings on Health Inspections, Quality of 
Care, and Nurse Staffing With COVID-19 Cases. JAMA. 2020;324(11):1103-
1105.
    \18\ Li Y., Temkin-Greener H., Shan G., Cai X. COVID-19 Infections 
and Deaths Among Connecticut Nursing Home Residents: Facility 
Correlates. J Am Geriatr Soc. 2020;68(9):1899-1906.

    In the often-contentious world of nursing home policy, it is 
difficult to find things that everyone agrees on--researchers, policy-
makers, advocates, and nursing homes themselves. Here's one thing 
everyone agrees on: On average, nursing homes lack sufficient numbers 
of staff to provide the quality care we would all want to receive. 
Having enough staff is arguably the single most important element in 
delivering high-quality care. Providing hands-on assistance to 
residents is at the heart of what nursing homes do. A large body of 
---------------------------------------------------------------------------
research confirms the importance of staffing to nursing home outcomes.

    It became clear during the pandemic that having enough staff was 
critical to implementation of best practices in preventing or 
containing COVID-19 outbreaks. These staffing-intensive practices 
include: testing of all residents, the physical separation of COVID-
positive and COVID-negative residents, and the assignment of dedicated 
staff to each group to avoid traffic between the two. At the same time, 
the ability of nursing homes to attract and retain sufficient staffing 
has been exacerbated by the pandemic: Staff were getting sick with 
COVID. Others were afraid of becoming infected, or of bringing the 
virus home to families, especially in the absence of adequate PPE. Some 
staff members had to stay home with children who were suddenly learning 
online. And it was difficult to find new staff to hire, for these same 
reasons and due to competition with hospitals for additional health 
care personnel. In the week ending February 21st, almost 17 percent of 
nursing homes reported a shortage of staffing.

    We specifically examined whether nursing homes that had higher 
staffing ratios just prior to the pandemic had better COVID-19 
outcomes. Having more staff did not reduce the probability of an 
initial outbreak. However, higher baseline staffing ratios were helpful 
in stemming an outbreak once it started: Nursing homes with the highest 
staff hours per resident-day experienced fewer cases and deaths than 
those at the bottom of the distribution. I should note that the effects 
of staffing are dwarfed by the effects of community spread,\14\ but 
increasing staffing represents a clear intervention that could improve 
care and can save lives, during the pandemic and beyond.
                            recommendations
    My research and the experiences in which I have been immersed for 
the past year suggest several policy recommendations moving forward:

    1.  First, CMS policies implemented during the past year that aim 
to ``incentivize'' nursing homes to handle the pandemic well (rewarding 
facilities that have few deaths and/or fining those that have many) are 
misguided. Some of these policies are valuable long-term strategies to 
encourage quality improvement. These are not appropriate in the midst 
of a crisis, particularly given the loose connection between nursing 
home actions and COVID-19 deaths. At the time of an outbreak, what is 
needed is not incentives or blame but rather assistance, especially to 
those facilities that are struggling with outbreaks and may be 
experiencing shortages of PPE, lack of access to rapid testing, or 
insufficient staffing. I therefore strongly support the allocation of 
American Rescue Plan funds to States for ``strike teams'' to rapidly 
fill these gaps during an outbreak.

    2.  Second, we must provide greater assistance to large facilities 
in communities of color. Such facilities do not typically earn 
performance bonuses. If we are not careful, incentive policies intended 
to promote best practices will instead exacerbate racial and ethnic 
disparities by depriving under-resourced facilities--and thus their 
patients and staff--of critically needed resources. All policies need 
to be evaluated in the light of equity concerns.

    3.  Third, data collection and wide availability are essential to 
assemble an accurate evidence base, to rapidly mobilize the clinical 
and policy research community, and to formulate effective policy. We 
would not have the evidence I discussed today without the data Congress 
mandated that the CDC and CMS collect and disseminate beginning last 
spring. Large gaps remain. Researchers cannot access facility-specific 
data on vaccination dates and rates or COVID-19 cases and deaths by 
race within nursing homes. This precludes rigorous analyses of the 
effects of vaccines, for example, or a patient-level analysis by race. 
Consumers who are considering nursing home care also have a right to 
know what percent of residents and staff have been vaccinated. These 
data need to be made available quickly.

    4.  Fourth, the COVID-19 pandemic underscores both the necessity 
and the limitations of traditional infection control measures and 
metrics. The American Rescue Plan puts substantial emphasis and funding 
into improving nursing home infection control practices. It is clear 
that these practices have been neglected and must be improved. At the 
same time, this is a solution to a relatively narrow set of problems, a 
solution that would not have avoided the tragedy of the past year. This 
brings me to my final and arguably most important recommendation.

    5.  Fifth, direct-care staffing in nursing homes needs to be 
increased. Even perfect infection control procedures will not improve 
safety of nursing home residents without the staff to implement them. 
In addition to low pay and few benefits, the job of direct-care nursing 
home staff is difficult, often dangerous, and emotionally and 
physically taxing. Add the risk of a potentially fatal infectious 
disease, and it's amazing they show up and that they stay. Addressing 
these challenges requires resources.

    Despite broad agreement that nursing home understaffing is a 
problem, there is less agreement about the root causes, and from where 
the resources should come. Many argue, and I largely agree, that 
America's long-term care system is underfunded. Nursing homes that rely 
on Medicaid cannot afford to increase staffing without additional 
reimbursement. At the same time, the dominance of for-profit ownership, 
the growing role of private equity, cross-subsidization from Medicare, 
and complex ownership arrangements such as related-party transactions 
make it difficult to see where taxpayer money is being spent, and what 
profit margins truly are. Greater transparency about these ownership 
structures is urgently needed. We only know that under current 
structures, the problem of understaffing has existed for decades; 
something is not working.

    In the short run, understaffed nursing homes cannot solve their 
shortages when faced with a COVID-19 outbreak. They need direct help in 
the form of strike teams. In the long run, resolving and moving beyond 
the debate about root causes of understaffing to improve these jobs and 
actually increase staffing is essential. This is, admittedly, a much 
harder problem to solve, but it is an essential one. We can't forget 
about this problem when the current pandemic is contained. We will 
never achieve adequate nursing home quality unless we find a way to 
attract and support the workforce providing the hands-on care. 
Addressing this challenge is the best way to honor the memory of more 
than 1,900 nursing home workers and more than 130,000 nursing home 
residents who have died from COVID thus far. We can't turn back the 
clock to prevent the tragedy of the past year. We can at least take 
steps to learn from it.

    Thank you for this opportunity to share my thoughts and expertise 
on the critical issue of the tragedy of the COVID-19 pandemic in 
nursing homes.

                                 ______
                                 
    Questions Submitted for the Record to R. Tamara Konetzka, Ph.D.
                 Questions Submitted by Hon. Ron Wyden
    Question. The Centers for Medicare and Medicaid Services (CMS) 
issued an interim final rule last year that required nursing homes to 
report COVID-19 data to the Centers for Disease Control and Prevention 
on a weekly basis beginning May 17, 2020. These data included COVID-19 
infections, COVID-19 deaths, and the availability of key equipment and 
workers at individual nursing homes. The data have proved to be helpful 
for the public, policy-makers, and industry stakeholders to track the 
pandemic, and related issues, in these care settings. However, to date, 
CMS has not required nursing homes to provide such data prior to May 8, 
2020, despite calls from Senate Democrats to do so. In September 2020, 
the Government Accountability Office (GAO) noted that ``by not 
requiring nursing homes to submit data from the first 4 months of 2020, 
HHS is limiting the usefulness of the data in helping to understand the 
effects of COVID-19 in nursing homes.'' GAO went on to recommend that 
``HHS, in consultation with CMS and CDC, develop a strategy to capture 
more complete data on COVID-19 cases and deaths in nursing homes 
retroactively back to January 1, 2020.''

    Do you support GAO's recommendation? Why or why not? Please briefly 
explain.

    Answer. I support GAO's recommendation. Having accurate data is 
essential not only to fighting a pandemic but to analyzing which 
practices and policies worked and which did not. I note that the issue 
is not only that nursing homes were not required to report COVID-19 
cases and deaths prior to May 8, 2020, but that they were not required 
even to specify whether they were including those earlier cases and 
deaths; thus, we cannot distinguish true zeroes from missing data. 
Analyses to date have had to make assumptions about how to handle those 
early months. Rigorous analyses based on more accurate data will help 
to fight the remaining challenges of this pandemic and to prepare 
better for the next one.

    Question. Residents and loved ones deserve to know whether a 
nursing home is safe when deciding where to receive their care. Such 
knowledge is more needed now than ever with the additional risk of 
COVID-19. The Five-Star rating system was created to do just that--
provide clear and meaningful information on the quality of nursing 
homes. The recent story in The New York Times (``Maggots, Rape and Yet 
Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public,'' 
March 13, 2021) was the latest evidence that this system needs to be 
fundamentally rethought. In many cases, research has shown that a 
facility that receives the system's top ratings does not necessarily 
provide better care or protection for nursing home residents when 
compared to lower-rated homes. Nursing homes may be able to game 
certain quality measures to keep or achieve high ratings while 
providing substandard care.

    What changes do you recommend to the Five-Star system so it will 
better reflect patients' outcomes of care and inform residents and 
loved ones about the quality and safety of nursing homes?

    Answer. I would like to start by pushing back a little against this 
characterization of the Five-Star system and adding some clarity about 
the evidence. While the system is certainly flawed and in need of 
constant refinement, I also believe it has substantial face validity. 
On average, 5-star nursing homes are significantly better than 1-star 
or 2-star homes in meaningful ways. Bad things sometimes happen in very 
good facilities, and some of the measures are susceptible to gaming, 
but this does not mean the entire rating system is fundamentally bad. 
After almost 2 decades of studying public reporting of nursing home 
quality, I can say that I would use (and have used) the Five-Star 
system myself to help choose a nursing home for family members. It 
should always be just a starting point for in-person visits and 
discussion.

    That said, I agree that improvement is needed. I recently published 
a review of the evidence on Nursing Home Compare and the Five-Star 
system (Konetzka et al., 2020). We concluded that two key areas of 
quality are completely missing from Nursing Home Compare (now Care 
Compare) and should be added: (1) measures of resident experience and 
quality of life; and (2) end-of-life care. Although improved safety is 
critical, the lack of attention to quality of life is arguably a much 
more important problem both in practice and in terms of what we measure 
and report. For long-stay residents, the nursing home is where people 
live, and yet our current system of measurement focuses solely on 
physical health. To the existing measures of physical health and safety 
I would also now add the need for reporting of COVID-19 vaccination 
rates among residents and staff; prospective residents need to know 
those rates in order to assess their risk.

    In terms of the accuracy of what is already reported, there are 
some issues to be solved. The most important component of the Five-Star 
rating is the inspection score, derived from State Medicare/Medicaid 
surveys for regulatory compliance. Although there are known problems 
with the survey system, it is considered the most objective because it 
is not based on facility-reported data. Suspicions of gaming usually 
focus on the staffing and the quality measures components. Our research 
shows nuanced evidence about this problem; blatant gaming exists, but 
the measures also lead to some true quality improvement (Davila et al., 
2020; Konetzka et al., 2020; Perraillon et al., 2017). The Centers for 
Medicare and Medicaid Services (CMS) has made several key improvements 
in recent years to try to minimize gaming. In particular, the flawed 
data system for collecting staffing data was replaced with a more 
reliable and detailed payroll-based journal system, and several quality 
measures were added that are based on Medicare claims data rather than 
facility-reported assessment data. These have reduced, though not 
eliminated, the opportunities for gaming.

    I think of quality measurement and reporting as an ongoing process 
of refinement; we will never reach a point where we think we have an 
ideal system. In terms of priorities in order to best inform consumers 
about the quality and safety of nursing homes, the addition of resident 
experience measures would address the most glaring problem with 
usefulness of the Five-Star system.

    Question. Many stories of poor quality, abuse, and neglect in 
nursing homes start and end with chronic understaffing. This is an 
issue that has existed for decades and has yet to be adequately 
addressed. In recent years, more than half of facilities had lower 
staffing levels than those recommended by experts, and 75 percent of 
nursing homes almost never met staffing levels required by CMS.\1\ The 
COVID-19 pandemic has exacerbated these existing issues, with nursing 
homes experiencing severe staffing shortages. Additionally, research 
shows that Black Medicare beneficiaries are more likely to be admitted 
to the lowest-quality nursing homes, which have lower ratios of nurses 
to residents.
---------------------------------------------------------------------------
    \1\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328494/.

    In your written and oral testimony, you spoke about the impact of 
staffing on quality of care and the racial disparities in quality of 
---------------------------------------------------------------------------
care.

    Would additional staffing requirements for Medicare, Medicaid, and 
certified nursing homes help to reduce racial disparities in the 
quality of care in these facilities?

    Answer. We know from research that nursing home residents of color 
are more likely to be in low-quality nursing homes with the lowest 
staffing ratios (Konetzka and Werner, 2009; Mor et al., 2004). So, to 
the extent that additional staffing requirements are most binding for 
those facilities and succeed in raising the floor for minimal staffing, 
these requirements will directly help to reduce racial and ethnic 
disparities in the quality of nursing home care.

    Question. What specific actions should Congress and/or CMS take to 
ensure that nursing facilities have a level of overall staffing that is 
concurrent with high quality care?

    Answer. There are multiple possible ways to increase staffing in 
nursing homes. The most direct way is to mandate minimum staffing 
ratios that are substantially higher than current ratios. This will 
likely necessitate an increase in Medicaid reimbursement in order to 
cover the additional costs of hiring more staff and paying them more, 
based on two premises: (1) current Medicaid reimbursement is too low to 
make meaningful changes to staffing ratios; and (2) meaningful 
increases in hiring will be difficult without an expanded workforce, 
and that expansion would require more attractive compensation 
(including higher wages, sick pay, and some benefits including health 
insurance).

    Several caveats apply to the need for higher reimbursement to 
increase staffing. First, the lack of transparency in the use of 
taxpayer dollars by nursing homes currently makes it difficult to 
assess the extent to which Medicaid rates currently have slack or need 
to be raised, although there seems to be general agreement and indirect 
evidence that they are too low. Thus, it would be helpful for any 
reimbursement increases to be tied to increased transparency about 
financial flows. Second, the increased reimbursement should be tied 
explicitly to spending on staffing.

    A final note is that minimum staffing ratios are just that--
minimal--and will likely be binding only for the lowest-quality 
facilities that currently have the most Medicaid residents and the 
fewest staff. Prioritizing these facilities makes sense. Substantially 
improving staffing across the entire industry would take more 
fundamental and multi-faceted rethinking of the way in which we deliver 
and pay for nursing home care.

    Question. In your written testimony, you discussed your support for 
the nursing home strike teams policy included in the American Rescue 
Plan Act as a way to fill gaps that facilities may be experiencing 
during the pandemic. You also indicated that you oppose the approach 
taken under the Trump administration, whereby the Department of Health 
and Human Services distributed $2 billion in incentive payments to 
nursing homes from the Provider Relief Fund based on their relative 
rates of COVID-19 cases and deaths.

    What information should HHS and States take into consideration when 
allocating these funds to ensure the facilities that need the most 
support preventing and responding to COVID-19 outbreaks receive it, and 
that racial disparities in nursing homes are taken into account?

    Answer. Assistance during a crisis needs to be allocated based on 
risk and need, not on some notion of merit. Strike teams and other 
emergency assistance need to get to nursing homes on the verge of an 
outbreak immediately. First, this requires HHS and states to ensure 
that facilities have adequate testing supplies and are testing at least 
as often as recommended by CDC guidance. A critical step is that once 
one or more cases are identified, all residents and staff need to be 
tested, and those who test positive need to be physically separated 
from those who test negative. Low-resourced facilities may struggle to 
implement these necessary steps with the required speed and may benefit 
from strike teams for assistance. The roles of HHS and the state need 
to include ongoing, regular communication with facilities about testing 
supplies, turnaround time for results, and the identification of 
positive cases, as well as the ability to send in strike teams 
immediately. The key is speed and regular communication.

    I don't believe it is necessary to specifically target nursing 
homes with more residents of color. Rather, policy-makers should 
prioritize areas and nursing homes at highest risk to make sure they 
get the assistance they need. Nursing home residents of color have been 
particularly hard hit during this pandemic because they are more likely 
to be in large nursing homes in areas where COVID-19 rates are high. If 
policy-makers focus assistance on areas and homes with the highest 
COVID-19 risk, the assistance will go disproportionately to residents 
of color, working to reduce the disparity.

    Finally, I repeat from my testimony that addressing a crisis should 
not be viewed in the same way as long-run efforts to improve the 
quality of nursing home care. Addressing a crisis may entail providing 
assistance to nursing homes that policy-makers view as ``undeserving'' 
due to underlying quality problems or for-profit status. The assistance 
can be in-kind or come with strings to make sure it is used for the 
intended purpose, but a crisis is not the time to implement an 
incentive and reward system, or the residents may pay the price.

    Question. A recent paper published by the National Bureau of 
Economic Research found that people who receive treatment in nursing 
homes owned by private equity firms have worse health outcomes than 
those living in facilities under other ownership structurers. This 
paper adds evidence to reports of worse outcomes associated with 
private equity's investment in the nursing home industry. Nursing homes 
have also become popular investments for real estate investment trusts 
(REITs), which often lease back properties to private equity firms or 
other related parties. The involvement of private equity in the nursing 
home industry has been of interest to the Finance Committee for more 
than a decade, and was a topic of interest for members during this 
hearing. In your testimony, you noted the urgent need for greater 
transparency regarding nursing home ownership structurers in light of 
``the dominance of for-profit ownership, the growing role of private 
equity, cross-subsidization from Medicare, and complex ownership 
arrangements such as related-party transactions,'' making it 
``difficult to see where taxpayer money is being spent, and what profit 
margins truly are.'' Please answer the following.

    If you have any other examples of issues associated with these 
ownership arrangements, please provide them.

    Answer. The paragraph above captures the essence of this problem. I 
do not have additional examples, but would like to describe my broader 
perspective on the role of private equity in the nursing home industry. 
The main advantage to society of a private-equity takeover in any 
sector is, in theory, the creation of efficiencies. The firm that is 
bought might have untapped potential for cost-cutting or a more 
profitable organizational structure, which private equity owners then 
capitalize on. Investors get a return and the resulting firm is leaner. 
In the nursing home sector, it is not clear that this is a desirable 
goal, even if health outcomes did not suffer. Efficiencies may be 
created, but they accrue neither to the taxpayer funding the care, nor 
to the patient getting the care. So, what great advantage does this 
increased efficiency bring? In a sector where the main challenge has 
been quality, for a population that often cannot advocate for itself, I 
don't see any advantage of private equity buyouts--with many potential 
downsides.

    Question. You noted the need for greater transparency in your 
testimony. Please provide specific recommendations about the types of 
transparency measures you suggest the Congress consider.

    Answer. First, requirements to clearly report all owners involved 
in related party transactions need to be enforced. Second, I would 
recommend improving financial transparency by (1) reinstating the 
requirement that nursing homes receiving Federal funding file annual 
Medicare cost reports; (2) requiring similar financial reporting across 
all related parties, such that profits and losses for the entire entity 
can be assessed; and (3) requiring similar financial reporting for 
chains as a whole. This type of reporting is a first step in 
calculating two critical data points for related policies--the percent 
of Medicare and Medicaid dollars spent on patient care, and the 
adequacy or inadequacy of Medicaid reimbursement rates.

    Transparency is not the end goal, but a necessary step to inform 
appropriate policy. At the same time, requiring transparency may reduce 
some of the incentive to engage in complex ownership arrangements.

    Question. Are you aware of any evidence or data that show residents 
or staff of facilities owned by private equity firms have fared worse 
or experienced worse outcomes during the COVID-19 pandemic?

    Answer. There have been two studies that I know of that directly 
examined this question (Braun et al., 2020; Gandhi et al., 2020). 
Somewhat surprisingly to many, neither of the studies found that 
nursing homes owned by private equity firms had worse COVID-19 
outcomes; in fact, results of the more rigorous study suggested that 
private-equity-owned nursing homes had better outcomes (Gandhi et al., 
2020).

    These findings are consistent with the rest of the evidence on 
COVID-19 outcomes which found that the underlying quality of the 
nursing home had little influence. One possible interpretation for the 
lack of an association is that the attributes of a nursing home 
required for providing high-quality care in normal times are not 
exactly the same attributes required for responding to a crisis. 
Anecdotally, especially early in the pandemic, containing an outbreak 
had more to do with procurement connections (to obtain testing and PPE) 
than with quality. It is possible that private-equity owners did not 
see large numbers of COVID-19 deaths being in the interest of 
profitability and that they possibly even assisted with procurement. 
Indeed, the article by Gandhi and colleagues found that private-equity-
owned nursing homes were less likely to have experienced shortages in 
PPE. Of note, outcomes were more negative for nursing homes that had 
been owned by private equity in the past, suggesting that once private-
equity owners sell a nursing home, any resource-related advantages 
disappear.

    Question. Section 6101 of the ACA sought to increase transparency 
of nursing home ownership structures. To date, CMS has not fully 
implemented or enforced this section of the ACA, although the agency 
does have existing reporting mechanisms for nursing home ownership that 
provide a certain amount of information to the public. As the committee 
considers the impacts of the changing ownership landscape in the 
nursing home industry, would implementing section 6101 provide 
sufficient transparency? Are there additional measures the committee 
should consider?

    Answer. Implementing and fully enforcing section 6101 would be 
helpful in identifying the parties involved in these complex ownership 
arrangements, which seems necessary but not sufficient. It is not clear 
to me that section 6101 would enable a financial analysis of where the 
money flows once these parties are identified. This broader financial 
analysis is critical to assessing the two issues I noted above: the 
percent of Medicare and Medicaid dollars spent on patient care, and the 
adequacy or inadequacy of Medicaid reimbursement rates. Estimates of 
these are essential for any policies aimed at improving the quality of 
nursing home care.

                                 ______
                                 
              Questions Submitted by Hon. Elizabeth Warren
    Question. Private equity facilities own approximately 11 percent of 
nursing homes nationwide.\2\ For years, reports have highlighted that 
private equity owned facilities provide worse care than other nursing 
homes. According to one 2014 study, private equity-owned facilities 
generally ``deliver poorer quality of care'' than other chain-
affiliated for-profit facilities; are likely to try to reduce cost by 
``substituting expensive but skilled RNs with cheaper and less skilled 
nurses''; and ``report significantly higher number of deficiencies'' 
that climb with more years of private equity ownership.\3\ A study 
released last month similarly showed found that private equity 
ownership of nursing homes ``increases the short-term mortality of 
Medicare patients by 10 percent, implying 20,150 lives lost due to 
[private equity] ownership over [a] 12-year sample period.''\4\ Private 
equity ownership was also associated with ``declines in other measures 
of patient well-being, such as lower mobility'' and taxpayer 
spending-per-episode increases of 11 percent.\5\ Meanwhile, an 
Americans for Financial Reform analysis of long-term care facilities in 
New Jersey found higher rates of COVID-19 infection and death at PE-run 
sites.\6\ However, it is challenging to identify specific ownership 
structures of nursing homes based on existing CMS data.\7\
---------------------------------------------------------------------------
    \2\ Skilled Nursing News, ``COVID-19 Brings Private Equity 
Investment in Nursing Homes Into the Spotlight,'' Alex Spanko, March 
19, 2020, https://skillednursingnews.com/2020/03/covid-19-brings-
private-equity-investment-in- nursing-homes-into-the-spotlight/.
    \3\ Journal of Health Care Finance, ``Private equity ownership of 
nursing homes: Implications for quality, June-July 2014'' Rohit Pradhan 
et al., October 2015, http://healthfinancejournal.
com/index.php/johcf/article/view/12.
    \4\ National Bureau of Economic Research, ``Does Private Equity 
Investment in Healthcare Benefit Patients? Evidence From Nursing 
Homes,'' Atul Gupta, Sabria T. Howell, Constantine Yannelis, and 
Abhinav Gupta, February 2021, https://www.nber.org/system/files/
working_papers/w28474/w28474.pdf.
    \5\ Id.
    \6\ Americans for Financial Reform, ``Report: The Deadly 
Combination of Private Equity and Nursing Homes During a Pandemic,'' 
August 6, 2020, https://ourfinancialsecurity.org/2020/08/report-3-
private-equity-nursing-homes-coronavirus/.
    \7\ Health Affairs, ``These Administrative Actions Would Improve 
Nursing Home Ownership and Financial Transparency in the Post COVID-19 
Period,'' Charlene Harrington et al., February 11, 2021, https://
www.healthaffairs.org/do/10.1377/hblog20210208.597573/full/.

    In studying the quality of care provided at American nursing homes, 
what challenges, if any, exist in identifying facility owners? How do 
those challenges affect researchers' ability to assess quality of care 
differences between for-profit and non-profit nursing homes, including 
---------------------------------------------------------------------------
homes owned by private equity firms?

    Answer. Enormous challenges remain in identifying nursing facility 
owners. Some progress has been made following provisions in the 
Affordable Care Act requiring nursing homes to reveal ownership 
structures, but these data are incomplete and unaudited. Depending on 
the research question, this is sometimes an impediment to conducting 
research on nursing home quality; it is not an impediment to 
comparisons of for-profit to nonprofit nursing homes but is an 
impediment when comparing chain-owned facilities by chain or with 
independent facilities. More importantly, it is a major impediment to 
assessing the flow of taxpayer money, the percent being spent on 
patient care, and the adequacy of payment rates.

    Question. What additional information, if any, could the Centers 
for Medicare and Medicaid Services collect on nursing home ownership 
that could aid regulators or researchers studying quality of care 
issues, or families seeking high quality nursing homes?

    Answer. It would be helpful to regulators and researchers to have 
more complete and audited data on ownership structures and cost reports 
that allow an assessment of the flow of taxpayer dollars, the percent 
that is being spent on patient care, and profit margins that take into 
account all related parties. It seems to me that not having these 
assessments presents a serious obstacle to meaningful policy change 
aimed at increasing the quality of nursing home care. If we don't know 
what the money is being used for, how can we tell if it is adequate or 
how much additional reimbursement is needed to produce the desired 
level of quality?

    It is less clear how families seeking high-quality nursing homes 
would use the ownership information, assuming they do not have strong 
prior beliefs about which ownership structures are associated with 
higher quality. We know that consumers sometimes view nonprofit status 
as a signal for quality, and that information is already available. As 
the research on these more complex ownership structures becomes 
clearer, the information could become more useful.

    Question. What improvements, if any, could the Centers for Medicare 
and Medicaid Services make in the presentation and public availability 
of nursing home ownership data--for example, in terms of formatting, 
update frequency, etc.--to help regulators or researchers studying 
quality of care issues, or families seeking high-quality nursing homes?

    Answer. For decades, it has been arduous or impossible to identify 
which nursing homes belong to which chains; the chain indicator 
available in CMS data reflects joint ownership of two or more 
facilities, not a very useful demarcation, and the chain name field is 
so inconsistent as to be useless. This makes rigorous research on 
chains difficult, and presents a barrier to the assessment of overall 
quality for particular chains. CMS could solve this issue by posting 
chain status and a consistently worded chain name on Care Compare, with 
updates as they occur.

    Question. What, if anything, has the COVID-19 pandemic revealed 
about the role of private equity in the U.S. nursing home industry and 
the safety of residents in private-equity-owned facilities?

    Answer. There have been two studies that I know of that directly 
examined this question (Braun et al., 2020; Gandhi et al., 2020). 
Somewhat surprisingly to many, neither of the studies found that 
nursing homes owned by private equity firms had worse COVID-19 
outcomes; in fact, results of the more rigorous study suggested that 
private-equity-owned nursing homes had better outcomes (Gandhi et al., 
2020).

    These findings are consistent with the rest of the evidence on 
COVID-19 outcomes, which found that the underlying quality of the 
nursing home had little influence. One possible interpretation for the 
lack of an association is that the attributes of a nursing home 
required for providing high-quality care in normal times are not 
exactly the same attributes required for responding to a crisis. 
Anecdotally, especially early in the pandemic, containing an outbreak 
had more to do with procurement connections (to obtain testing and PPE) 
than with quality. It is possible that private-equity owners did not 
see large numbers of COVID-19 deaths being in the interest of 
profitability and that they possibly even assisted with procurement. 
Indeed, the article by Gandhi and colleagues found that private-equity-
owned nursing homes were less likely to have experienced shortages in 
PPE. Of note, outcomes were more negative for nursing homes that had 
been owned by private equity in the past, suggesting that once private-
equity owners sell a nursing home, any 
resource-related advantages disappear.

    Question. What steps do you believe the U.S. Congress should take 
to minimize risks to patients living in private-equity-owned nursing 
facilities, including but not limited to risks related to staffing, 
infection control, and future pandemics?

    Answer. I do not believe that private equity should have a role in 
owning nursing homes, so some steps on the part of the U.S. Congress 
are warranted. There are several ways to reduce the growth in private-
equity ownership. One is to simply ban these leveraged buyouts; given 
the extent of public funding for nursing home care, this could be 
justified. Another is to make the nursing home sector much less 
attractive to private equity. This might be achieved through policies 
that simultaneously work to improve the quality of care and would serve 
to protect those already living in facilities owned by private equity: 
requiring minimum staffing ratios and requiring that a certain 
percentage of revenues be spent on patient care.

                                 ______
                                 
               Questions Submitted by Hon. John Barrasso
    Question. An article in the March edition of Health Affairs points 
out that although staff turnover is an important indicator of nursing 
home quality, this has never been included on the Nursing Home Compare 
website, maintained by Medicare.

    Please discuss the impact of staffing turnover on the quality of 
care provided in nursing homes.

    Answer. A fairly large body of evidence suggests that nursing homes 
with higher staff turnover have lower quality of care. The research is 
of mixed quality, with two main challenges. First, national data on 
turnover have not been available until very recently with the 
implementation of the payroll-based journal system, the data used in 
the Health Affairs article. Thus, most studies of turnover are small 
and localized. Second, while high turnover is associated with poor 
quality, the causal connections are unclear. Does high turnover lead to 
poor outcomes, or do nursing homes with low quality just have more 
trouble retaining staff? In any case, there is face validity to a 
causal relationship: If staff members do not stay long enough to get to 
know residents and their needs, problems and changes may go unnoticed 
and communication may be lost in the frequent transitions.

    Question. Specifically, do you believe turnover rates from nursing 
homes should be made more readily available for public review?

    Answer. I would not prioritize it, though it could do some good. 
Public reporting has two main goals: to provide information to 
consumers and to incent improvement by providers. For consumers, the 
question I would ask is: Would posting turnover rates tell them 
anything new? As established in the Health Affairs article, turnover 
rates are highly correlated with the overall star ratings in the 
direction one would expect. Thus, adding turnover rates to the system 
would be unlikely to change consumers' choices, though perhaps some 
consumers would be particularly interested in this measure. I would be 
much more enthusiastic about adding patient experience measures, which 
are central to how we think about quality in long-term care but are 
completely missing from Care Compare.

    Even if not very useful to consumers, publicly reporting turnover 
rates could lead providers to pay more attention to turnover and to try 
to reduce it. For this reason, there may be some benefit to public 
reporting of turnover rates. I still believe the need for it is 
outweighed by the compelling need to add patient experience measures.

                                 ______
                                 
                 Questions Submitted by Hon. Todd Young
    Question. As outlined in many of your testimonies, the visiting 
restrictions and isolation necessitated by the COVID-19 pandemic took a 
heavy toll on the emotional and mental health of many nursing home 
residents separated from their family members and other loved ones. 
Fortunately, with increased vaccination and declining COVID-19 deaths, 
many of these restrictions have been lifted.

    While we hope that restrictions of this scale will not be necessary 
again, it is worth examining ways to alleviate the negative emotional 
and mental health effects that isolation may have on nursing home 
residents. The use of technology, for one, has allowed residents to 
interact virtually with family and other loved ones from whom they are 
otherwise separated. Expanded use of telehealth has also helped 
residents access routine health-care services while limiting spread of 
the coronavirus.

    What are some lessons learned from the public health emergency in 
terms of the integration of technology in nursing homes--both in 
helping residents visit virtually with loved ones and in accessing 
health-care services?

    Answer. The expanded use of technology has been one of the silver 
linings of this pandemic across health-care sectors, even though it 
cannot fully substitute for in-person interaction and contact. This has 
been true in nursing homes as well, with some caveats. One caveat is 
that many older adults, especially those with dementia, are 
uncomfortable with these technologies. Another caveat, related to the 
first, is that using them requires time and effort of nursing home 
staff to facilitate. Nursing homes have exhibited understaffing for 
decades and this was exacerbated during the pandemic, so facilitating 
video visits became another task on the list competing for staff time. 
Nonetheless, while I am not aware of large-scale studies examining the 
effects of video visits in nursing homes, it seems safe to say that 
they mitigated the effects of social isolation to some extent and 
allowed family members some ability to monitor the mental and physical 
well-being of the resident.

    Question. How do you anticipate this type of technology continuing 
to be used beyond the pandemic?

    Answer. I expect that the use of technology to facilitate video 
visits with family and health-care providers will become standard. Even 
without the need for social isolation, there are numerous situations in 
which an in-person visit is not possible or not advised, for example 
when a family member lives far away or is ill. Increased use of 
televisits may also reduce the need for some transfers of residents for 
routine health care. It could also enable more frequent monitoring and 
may be a cost-
effective way to enable some to remain at home, and out of the nursing 
home, a little longer.

                                 ______
                                 
                 Question Submitted by Hon. John Cornyn
    Question. Your testimony notes the lack of vaccine uptake by 
nursing home staff. This coupled with high turnover can lead to higher 
risks for residents.

    What recommendations do you have to address the issue of vaccine 
reluctance and improving staff retention?

    Answer. Vaccine hesitancy among nursing home staff is a significant 
problem. To the extent that some of the hesitancy is due to the 
vaccines being new and people wanting to gather evidence about how 
others have fared, rates should increase as time passes. There are also 
several things that policy-makers and nursing home managers can 
actively do: (1) continue to provide education and public health 
messaging about the safety and efficacy of the vaccines and the dangers 
of COVID-19; and (2) make the logistics of getting the vaccine easy, 
e.g., through repeated on-site vaccine clinics for staff and new 
residents. If staff who originally declined now have to find their own 
appointments for vaccines off-site, it will be a significant obstacle 
to increasing take-up. Other small nudges may also help, such as 
requiring unvaccinated staff to wear more protective equipment. While 
the vaccines are still under Emergency Use Authorizations, any more 
significant nudges (such as bonuses) or mandates seem ethically 
questionable.

    Improving staff retention is a bigger problem that will require 
fundamental policy reforms. It is difficult to imagine making anything 
but small, incremental progress unless we change the way we treat 
nursing home and home health caregivers. As long as they make minimum 
wage and often have no sick pay or benefits or promotion prospects 
while doing physically and mentally demanding work, there will be 
understaffing and there will be turnover; understaffing and turnover 
tend to move together. Increasing Medicaid reimbursement and tying it 
to increased staffing would be a start.

                                 ______
                                 
               Questions Submitted by Hon. James Lankford
    Question. During the hearing, you mentioned the benefits of States 
having essential caregiver programs.

    What are other ways States and localities can encourage increased 
family engagement and oversight in order to ensure the proper safety of 
a facility for their loved one? In what ways can Federal entities like 
CMS ensure participants in family engagement programs, such as 
essential caregivers, are given the utmost access to information 
regarding their loved one?

    Answer. Family engagement and oversight are critical to the well-
being of nursing home residents, not just for safety but for quality of 
life. Although they are not always mutually exclusive, I believe that 
safety and clinical outcomes are too often prioritized over quality of 
life, in part because safety and clinical outcomes are what we measure 
and reward. During the pandemic, I believe that CMS should have 
encouraged (or even mandated) all States to adopt essential caregiver 
programs, while providing the testing and PPE resources to do so 
safely. Any increased COVID-19 risk (likely small) would have been 
outweighed by the benefits of these interactions.

    I see two main impediments to full communication and resident 
engagement with family members, both of which exist in more normal 
times but were exacerbated by the pandemic. The first concerns fears of 
regulatory action or litigation if negative information is disclosed. A 
fear-based system is never conducive to openness; there should be some 
reward to being fully transparent and open, perhaps in the form of 
reduced risk of regulatory sanctions or litigation.The second main 
impediment is resources. Although families often help with care, full 
communication with families and the facilitation of family engagement 
requires time and effort on the part of nursing home managers and 
staff. We have a system of nursing home care in which, for many 
facilities, there seems to be a crisis every day. During the pandemic, 
this was the case for most facilities. When staffing is so short that 
basic care needs are being neglected, communication with families is 
unlikely to be prioritized. Solving this issue will require significant 
reforms, likely involving increased Medicaid reimbursement tied to 
higher staffing standards.

    One additional way to improve openness and communication with 
families is to publicly report resident and family satisfaction with 
the level of communication. In a review of the evidence on Nursing Home 
Compare that I recently published (Konetzka et al., 2020), we 
identified resident and family experience and satisfaction as a 
critical gap in what we report, and communication would be an element 
of that addition. We know that providers tend to focus on what is 
measured and what is reported, so this could help, at least 
incrementally.

References

Braun, R.T., Yun, H., Casalino, L P., Myslinski, Z., Kuwonza, F.M., 
        Jung, H.Y., and Unruh, M.A. (October 1, 2020). Comparative 
        Performance of Private Equity-Owned US Nursing Homes During the 
        COVID-19 Pandemic. JAMA Network Open, 3(10), e2026702. https://
        doi.org/10.1001/jamanetworkopen.2020.26702.
Davila, H., Shippee, T.P., Park, Y.S., Brauner, D., Werner, R.M., and 
        Konetzka, R.T. (September 28, 2020). Inside the Black Box of 
        Improving on Nursing Home Quality Measures. Med Care Res Rev, 
        1077558720960326. https://doi.org/10.1177/1077558720960326.
Gandhi, A., Song, Y., and Upadrashta, P. (August 28, 2020). Have 
        Private Equity Owned Nursing Homes Fared Worse Under COVID-19? 
        (August 28, 2020). Available at SSRN: https://ssrn.com/
        abstract=3682892 or http://dx.doi.org/10.2139/ssrn.3682892. 
        SSRN preprint. http://dx.doi.org/10.2139/ssrn.3682892.
Konetzka, R.T., and Werner, R.M. (October 2009). Disparities in long-
        term care: Building equity into market-based reforms. Med Care 
        Res Rev, 66(5), 491-521. https://doi.org/1077558709331813 [pii] 
        10.1177/1077558709331813.
Konetzka, R.T., Yan, K., and Werner, R.M. (2020). Two Decades of 
        Nursing Home Compare: What Have We Learned? Medical Care 
        Research and Review [published online ahead of print, June 13, 
        2020].
Mor, V., Zinn, J., Angelelli, J., Teno, J.M., and Miller, S.C. (2004). 
        Driven to tiers: Socioeconomic and racial disparities in the 
        quality of nursing home care. Milbank Q, 82(2), 227-256.
Perraillon, M.C., Brauner, D.J., and Konetzka, R.T. (August 1, 2017). 
        Nursing Home Response to Nursing Home Compare: The Provider 
        Perspective. Med Care Res Rev, 1077558717725165. https://
        doi.org/10.1177/1077558717725165.

                                 ______
                                 
  Prepared Statement of Quiteka Moten, MPH, CDP, State Long-Term Care 
   Ombudsman, Commission on Aging and Disability, State of Tennessee
                               biography
    Quiteka ``Teka'' Moten works for the Tennessee Commission on Aging 
and Disability as the State Long-Term Care Ombudsman. Teka is from 
Memphis, TN and is a graduate of the University of Tennessee--Knoxville 
with a B.A. in interdisciplinary studies and a B.A. in sociology. 
Following undergrad, Teka worked as senior programs coordinator for the 
YWCA in Knoxville. Next, she managed programs and policy efforts for 
the Alzheimer's Association in South Central Tennessee. During this 
time, she worked to establish rural senior networks, train first 
responders, and manage early-stage engagement programs and respite 
grants.

    Following her time with the Alzheimer's Association, Teka pursued 
her master of public health in behavioral sciences at Tennessee State 
University while working as a government contractor. Passionate about 
supporting caregivers, Teka has spent years assisting families affected 
by Alzheimer's and other dementias. Through providing hands-on 
training, care plan management, and respite referrals, Teka makes use 
of her Certified Dementia Practitioner and PAC Dementia Coach 
designations by training caregivers and health-care professionals. She 
has made appearances on several local television and radio programs 
throughout the State and southern region--most notably are her features 
in NPT's ``Aging Matters'' series.
                overview of the ombudsman program (omb)
    The Long-Term Care Ombudsman Program (LTCOP) is an essential 
component to the oversight of communities such as skilled nursing 
facilities, assisted care living facilities, and residential homes for 
the aged, or (SNFs, ACLFs, and RHAs). There are 1,362 staff Ombudsmen 
(FTE) including 50 States along with DC and Puerto Rico and 5,947 
designated volunteer Ombudsmen in the Nation. For context's sake, there 
are 16,253 nursing facilities per NORS 2019, Total Counts.\1\
---------------------------------------------------------------------------
    \1\ See Aging, Independence, and Disability (AGID) Program Data 
Portal: https://agid.acl.gov/DataGlance/NORS/.

    The structure of each State Long-Term Care Ombudsman Program varies 
based upon organizational criteria developed by NASUAD (National 
Association of States United for Aging and Disabilities).\2\ Major 
activities of the Tennessee Long-Term Care Ombudsman Program include 
required visits, reporting, mandatory meetings with other State 
agencies, follow-up on facility-initiated discharges, and coordination 
of the volunteer Ombudsman programs (VORs).
---------------------------------------------------------------------------
    \2\ State Long-Term Care Ombudsman Programs: Organizational 
Structure: https://ltcombudsman.org/uploads/files/support/NASUAD-2016-
Ombudsman-Rpt.pdf.

    The cases for the LTCOP are resolved through complaint 
investigations as laid out in the CMS State Operations Manual. LTCOP 
representatives investigate individual complaints and address concerns 
that impact residents in facilities. Long-Term Care Ombudsmen (LTCOs) 
can also address general concerns they personally observe during a 
visit (e.g., odors, concerns about the environment, staff not knocking 
on resident doors before entering rooms.) As LTCOPs are resident-
directed, LTCOs cannot share information without resident consent. 
Investigations by LTCOP representatives are done to gather facts, but 
---------------------------------------------------------------------------
the main goal is to resolve the issue to the residents' satisfaction.

    The LTCOP operates as a community-based, bedside advocacy program 
working to uphold residents' rights. The Nursing Home Reform Act 
established the following Residents' Bill of Rights:\3\
---------------------------------------------------------------------------
    \3\ The 1987 Nursing Home Reform Act: https://www.aarp.org/home-
garden/livable-communities/info-2001/
the_1987_nursing_home_reform_act.html.

      The right to live in a caring environment free from abuse, 
mistreatment, and neglect.
      The right to live without the fear of enduring physical 
restraint.
      The right to privacy.
      The right to receive personal care that accommodates physical, 
medical, emotional, and social needs.
      The right to a social contact/interaction with fellow residents 
and family members.
      The right to be treated with dignity.
      The right to exercise self-determination.
      The right to exercise freedom of speech and communicate freely.
      The right to participate in the creation and review of one's 
individualized care plan.
      The right to be fully informed in advance of any changes to care 
plan or status of the nursing home.
      The right to voice grievances without discrimination or 
reprisal.
                   how covid impacted the omb program
    COVID and the ensuing policies disrupted the Ombudsman Program's 
immediate access to residents (as provided for in the Code of Federal 
Regulations). The inability to have face-to-face meetings made it 
difficult to verify complaints, assure confidentiality and readily gain 
consent from residents and/or their medical surrogates. It also made it 
difficult to advocate for residents dealing with facility-initiated 
discharges (oftentimes leaving them in behavioral health or medical 
centers with the risk of losing Medicaid). Particularly affected by 
these issues were people living with dementia (PLWD); those who were 
aphasic or unable to speak; those who were deaf, hard of hearing or, 
have assistive technology needs; those without the manual dexterity to 
use a phone; and those without funds to purchase their own.

    In addition, the workforce shortage in nursing homes was further 
exacerbated by COVID. Lack of staffing and an inability to be with 
their family had a major impact on residents. Some of the complaints 
received by the Tennessee Long-Term Care Ombudsman Program included:

      An overall decline in quality of care in many facilities;
      Unanswered call lights, not getting basic care/assistance, and 
dehydration;
      Issues with repositioning which left residents in bed resulting 
in an exponential increase in bed sores;
      Unchanged catheters and pressure sores resulting in sepsis and 
death;
      Issues of dignity and hygiene stemming from residents having to 
sit in their own urine and feces for hours;
      Delayed discharges to hospitals for treatment of serious 
conditions, facility-
initiated hospice;
      Communication issues with facilities and privacy concerns by 
families;
      Resident isolation (resulting in emotional distress and leading 
to physical decline); and
      COVID infection cases, issues surrounding cohorting residents, 
and room changes.
                               solutions
    There are a few contemplations as the Tennessee State Long-Term 
Care Ombudsman:

    1.  There is a need to reform the strategy of recruiting and 
retaining staff support especially with a rapidly growing elderly 
population.
    2.  It's fair to make the argument that LTCOP's are an essential 
piece of the system that seeks to respond to and support the health, 
safety, and welfare of residents regardless of any status a State may 
have bestowed upon the program.
    3.  There is a need for more Geri-psych units. Residents are 
typically held for 2 weeks if sent out by nursing homes; that is 
usually not enough time for the medications residents received to cycle 
out of their systems and then hold the resident for observation.
    4.  There should be an established, uniform system for 
communicating with families in the event of a PHE or natural disaster.

                                 ______
                                 
     Questions Submitted for the Record to Quiteka Moten, MPH, CDP
                 Questions Submitted by Hon. Ron Wyden
    Question. The Centers for Medicare and Medicaid Services (CMS) 
issued an interim final rule last year that required nursing homes to 
report COVID-19 data to the Centers for Disease Control and Prevention 
on a weekly basis beginning May 17, 2020. These data included COVID-19 
infections, COVID-19 deaths, and the availability of key equipment and 
workers at individual nursing homes. The data have proved to be helpful 
for the public, policy-makers, and industry stakeholders to track the 
pandemic, and related issues, in these care settings. However, to date, 
CMS has not required nursing homes to provide such data prior to May 8, 
2020, despite calls from Senate Democrats to do so. In September 2020, 
the Government Accountability Office (GAO) noted that ``by not 
requiring nursing homes to submit data from the first 4 months of 2020, 
HHS is limiting the usefulness of the data in helping to understand the 
effects of COVID-19 in nursing homes.'' GAO went on to recommend that 
``HHS, in consultation with CMS and CDC, develop a strategy to capture 
more complete data on COVID-19 cases and deaths in nursing homes 
retroactively back to January 1, 2020.''

    Do you support GAO's recommendation? Why or why not? Please briefly 
explain.

    Answer. I agree with the recommendation by GAO to ``develop a 
strategy to capture more complete data on COVID-19 cases and deaths in 
nursing homes retroactively back to January 1, 2020.'' Unfortunately, 
this is needed because the cases and deaths in nursing homes often 
mirrored that of their counties/communities. By contrast, this was not 
the case in many hospitals and Emergency Department (or ED) settings. 
With that, exploration into the complete data would help better examine 
the transmission of COVID earlier on in skilled nursing facilities and 
other long-term care facilities. The standards for care in each State 
spell out required documentation that may assist in accomplishing data 
collection.

    Question. During the hearing, several Senators and witnesses raised 
the importance of the Federal Government collecting and publishing 
information from individual nursing homes that show the rate of 
vaccinations for residents and staff. Since that time, a bipartisan 
group of senators have sent a letter to the U.S. Department of Health 
and Human Services calling on it to take steps to begin this data 
collection.

    Do you support this type of information being made public? How 
would it help the work of Long-Term Care Ombudsmen and their role 
protecting the rights of residents in nursing homes and other 
congregate living facilities?

    Answer. Information on residents' vaccination percentages should 
and have been made public through Federal Pharmacy Partnerships and 
respective QIOs. Allowing the publication of information on staff 
vaccination percentages, however, is a bit more difficult to weigh in 
on due to risk of exposing PHI (like HIPPA) and leaving staff 
vulnerable to pressures by other staff and their community as a result. 
Nonetheless, the Ombudsman Program and other pertinent State agencies 
should be privy to this information--even if aggregated--so that we 
have a better understanding of risks for residents and their families 
as well as our own. This would also help to inform conversations around 
re-entry practices and needs for targeting community education to 
encourage vaccination(s) where possible. In addition, for Ombudsman 
Programs and other stakeholders working on respective ad hoc State 
COVID committees, this information would assist in continuing to form 
expectations for visits as we hopefully move closer to herd immunity.

    Question. In preparation for this hearing, Oregon's Ombudsman 
provided my office with reports documenting issues that long-term care 
residents in the State have faced over the last year. They read like a 
list of nightmares. The Oregon Ombudsman received reports of residents 
being left in soiled clothing for hours, patients that developed 
pressure sores that reached bone, and falls that went unreported by 
facilities. These types of problems aren't unique to Oregon. Yet, it's 
clear the pandemic has reduced basic protections of the Nation's most 
vulnerable.

    How has the pandemic impacted your work looking out for the well-
being of nursing home residents, and how did the pandemic affect the 
number and types of complaints your office received?

    Answer. The pandemic impacted the mechanisms for consumer 
protection and advocacy of residents by hindering immediate access. 
Without the ability for families or the Ombudsman Program (and in some 
instances first responders) to readily gain facility access, instances 
of neglect, abuse, exploitation, and untreated medical conditions that 
did not rise to the level of immediate jeopardy, or IJs, often times 
went unreported. In addition, due to visitation restrictions, Ombudsmen 
were unable to make quarterly visits to skilled nursing facilities 
albeit a Federal requirement--and a source of many of the cases opened 
by virtue of in-person observation. With that, nationally, the 
Ombudsman Program saw a decrease in complaints throughout the first 
wave of COVID. However, our offices were inundated with calls and 
concerns for visitation and care questions that may not have risen to 
the level of opening a case/complaint resulting in an exponential 
increase in Information and Assistance calls to the Ombudsman Program.

    Question. The Centers for Medicare and Medicaid Services issued new 
visitation guidance on March 10, 2021, that will make it easier for 
nursing home residents to receive visitors. Do you expect that the 
administration's policy will make it easier for you to do your job 
looking out for the safety of long-term care residents?

    Answer. The new guidance visitation issued on March 10, 2021 was 
merely 3 days short of having been in place for an entire year, so the 
new guidance was obliging in many respects with a few reservations. The 
visitation guidance was helpful in reestablishing expectations for 
allowing residents their rights to visit (or guardrails if you will--
especially in States that were no longer following State specific 
guidance). So, short answer--yes, it makes our job easier cause we 
finally have good news to share. In addition, what resulted from the 
guidance was hope for residents and families--but for facility staff 
and State government, its immediacy placed a strain on areas that were 
still experiencing high rates of positivity, COVID outbreaks, or staff 
testing positive. Lastly, there was seemingly vague language that went 
weeks without clarity until national webinars.

                                 ______
                                 
                Question Submitted by Hon. John Barrasso
    Question. A top concern of Wyoming nursing facilities is making 
sure there are enough staff to care for residents.

    Many Wyoming nursing homes provide professional development and 
other educational opportunities to attract and maintain their staff.

    Can you discuss solutions related to workforce development you 
believe will improve the ability of nursing facilities to attract and 
maintain direct care staff?

    Answer. Perhaps the most polarizing issue for long-term care 
facilities during COVID was the workforce shortage. The concern speaks 
to a few issues--lack of childcare, education equity, corporate 
responsibility, and general fiduciary oversight, but most importantly--
quality of care for residents. Providing care in a nursing home setting 
is tough! It requires physical strength and often mental restraint; we 
received a myriad of complaint calls from staff detailing just that.
              solutions for workforce development include:
        Temporary CNAs progression: Working through a process for 
temporary CNAs based on education and time in facility during the 
pandemic.
        WIOA grants: Consideration for collaboration with WIOA 
Eligible Training Programs to award additional funds to students 
working towards non-credit certifications who are willing to do both 
school and work in facilities.
        Childcare provision: Developing childcare centers in wings of 
facilities that are not at full census for staff who are single parents 
and/or may not qualify for assistance.
        Student Loan Forgiveness: Quite possibly the greatest way to 
attract almost anyone who has amassed quite a bit of debt.

                                 ______
                                 
                 Questions Submitted by Hon. Todd Young
    Question. As outlined in many of your testimonies, the visiting 
restrictions and isolation necessitated by the COVID-19 pandemic took a 
heavy toll on the emotional and mental health of many nursing home 
residents separated from their family members and other loved ones. 
Fortunately, with increased vaccination and declining COVID-19 deaths, 
many of these restrictions have been lifted.

    While we hope that restrictions of this scale will not be necessary 
again, it is worth examining ways to alleviate the negative emotional 
and mental health effects that isolation may have on nursing home 
residents. The use of technology, for one, has allowed residents to 
interact virtually with family and other loved ones from whom they are 
otherwise separated. Expanded use of telehealth has also helped 
residents access routine health-care services while limiting spread of 
the coronavirus.

    What are some lessons learned from the public health emergency in 
terms of the integration of technology in nursing homes--both in 
helping residents visit virtually with loved ones and in accessing 
health-care services?

    Answer. The major lesson of technology in nursing homes is that it 
is only as good as (1) the staff's familiarity with the software/
hardware; and (2) their capacity to use it in a meaningful, person-
centered way. While there are success stories as it pertains to 
telehealth and visitation, the reality is that many residents didn't 
reap the benefits of technology due to the shortage of staff to meet 
their care needs. For many in nursing homes, much of the care residents 
required was outside a facility and could not be provided via 
telehealth. And due to transmission-based protocols and fear of 
quarantine, many residents went without medical care to avoid a 2-week 
lockdown; in some instances, this included treatments like dialysis, 
dental appointments/denture fittings, eye appointments, and other 
medical circumstances that contribute to the quality of life for older 
and vulnerable people.

    Technology, while great as a concept and expenditure, is up to the 
discretion of facilities. What we also learned about technology is that 
there was:

        An increase in use for end-of-life visits 
(especially for long-distance caregivers).
        An increase in use for cases in which APS, TBI, or 
VAPITs were involved.
        A contingency on its use depending on staffing 
capacity at nursing homes. In facilities where community transmission 
was mirrored, it meant that use of technology for communication took a 
back seat to pushing paperwork and water carts.
        There should be some consideration for standards on 
virtual care plans and facility-initiated medical transfers to keep 
families involved in the process and able to lay eyes on their loved 
ones amidst tough decisions being made if ever visitation restrictions 
are put back in place.

    Question. How do you anticipate this type of technology continuing 
to be used beyond the pandemic?

    Answer. Beyond the pandemic--as more baby boomers age into Medicare 
and the long-term care setting daily, I think there will be an uptick 
in technology use. For many of those working in the almost $80-billion 
elder care industry, it means the realization of a paradigm shift to 
accompany the next generation. This mean not only reconsidering the 
institution of skilled nursing facilities by design and activity 
offering, it means:

        Using technology for person-centered care of residents while 
protecting their Personal Health Information, or PHI. If I had a magic 
wand, there would be a means to personalize the experience of each 
resident based on their intake info and schedule including pre-loaded 
songs and movies that they genuinely enjoyed throughout childhood 
through to present day.
        Taking the opportunity to engage children and younger adults 
on an intergenerational level; they could assist with programming 
tablets and/or teaching residents how to work the equipment.
        Retrofitting facilities to accommodate the needs and wants of 
a generation who has a better grip on technology and a desire to have 
it daily; there are several Life and Safety considerations forthcoming 
for State departments of health.
        Welcoming a more vocal generation into facilities that is 
aware of technology and its many uses. This means conversations and 
State bill introductions about technological equipment like smart 
speakers, gadgets like smart displays for video chatting, and features 
like AI-infused smart camera and smart sound.

    Question. You mentioned the need for a uniform system for 
communicating with families in the event of a public health emergency 
or natural disaster. Could you elaborate on this recommendation?

    Answer. In May 2020, the first of many requirements to notify 
families of COVID was released by CMS. At that time, the guardrails 
issued to inform families were broad to say the least. A skilled 
nursing facility could select a myriad of ways to inform loved ones 
including phone calls, automated calling services, text services, and 
notices on facility/corporate home pages. Because novel coronavirus was 
just beginning to take its toll, there was not yet a system in place to 
deal with thoroughly explaining visitation restrictions/outbreaks, lack 
of immediate access, and an inability for families to present when 
needed to (1) interpret changed behavior, mood, or effect of loved 
ones; and (2) have face-to-face discussions on care plans--and ensure 
follow-through in person. This along with the workforce shortage led to 
many facility phones going unanswered due to amount of staff, repeat 
calls, calls from multiple family members of the same resident, request 
from media, etc.

    As we inch closer to herd immunity, the reality is that we should 
use this time to devise a system by which families can readily 
communicate with loved ones in facilities during public health 
emergencies. Priority should be given to a system by which families are 
notified when there is a facility-initiated hospital or Geri-psych 
transfer along with facility-initiated hospice--none of these should 
come as a surprise to families or happen without their consent 
haphazardly unless it is a medical or behavioral emergency. This 
ideally would be executed through a text messaging alert system 
coordinated by Skilled Nursing Facilities, local health departments, 
QIOs, the Ombudsman Program, and State departments of health.

                                 ______
                                 
   Prepared Statement of Adelina Ramos, Certified Nursing Assistant, 
             SEIU District 1199 New England, Greenville, RI
    Thank you to Chairman Wyden, Ranking Member Crapo, and members of 
the Senate Finance Committee for inviting me to speak today. My name is 
Adelina Ramos, and I'm a CNA at a nursing home in Greenville, RI. I am 
a proud immigrant to this country, having moved here from Cape Verde 
Islands off the western coast of Africa when I was child.

    At my facility, I work with Alzheimer's patients. To be trusted by 
families in my community to care for their loved ones is a great 
privilege and honor. But over the past year, my days have been filled 
with fear and sadness.

    I don't think anyone in my small Rhode Island community thought 
COVID-19 would arrive at our doorstep. But it did, and nursing homes 
were not prepared. When COVID first hit, we lost over 20-plus residents 
in just over a month. A CNA at my facility died too, and she was one of 
the first nursing home workers to die of COVID in Rhode Island.

    As more and more people in my facility tested positive, we 
confronted management to let them know we didn't have the right PPE--
and what we had wasn't enough to last--or training to keep our 
residents safe and prevent the virus from spreading in our facility.

    We were extremely short-staffed too. At one point I was caring for 
26 critically ill residents with only the help of one other CNA, a 
nurse and a housekeeper. My residents couldn't eat or drink without 
help. They couldn't move or get out of bed by themselves. They all 
required oxygen changes every 15 minutes. And because they had 
Alzheimer's, sometimes they would get very scared or angry.

    It was horrifying. But management didn't seem to be too concerned 
when my co- workers and I told them what was going on. We pleaded for 
more staff on each shift, but they said they couldn't find anyone. And 
so our residents and staff kept getting sick. They kept dying.

    On Mother's Day, I realized I couldn't smell my ginger tea. I 
thought it was because of my mask. I knew that was one of the symptoms 
of COVID, but I wasn't experiencing anything else. When the National 
Guard arrived to test people a few weeks later, I got the news I had 
been dreading for so long: I was COVID-positive. I was asymptomatic, 
and so I was unknowingly putting those around me at risk--at work and 
at home.

    My in-laws live with us, and I serve as their caregiver. They are 
both in their late sixties and have preexisting conditions that put 
them at high risk of contracting a serious case of COVID-19. I was 
worried about infecting my husband, because then he wouldn't be able to 
see his parents.

    As a mother, I never thought I'd have to tell my 15-year-old son to 
stay away from me. Don't touch me. Don't hug me. Don't get too close. I 
knew I would never be able to forgive myself if I passed this deadly 
virus on to my child. So I did what I had to do to keep him safe, even 
though it broke my heart into a million little pieces.

    Today, I'm COVID-free and vaccinated, and I can finally hold my son 
close and care for my in-laws again. Things are looking up, but the 
physical and emotional trauma this pandemic caused can't be cured with 
a shot in the arm.

    When I started working at a nursing home, I understood I'd have 
residents pass away. But when that happens, our job is to make sure 
they're comfortable, cared for and surrounded by loved ones in their 
final moments. But because of the pandemic, family members couldn't 
come into our facility to be with their dying parents, grandparents, 
siblings, or friends. Normally, when someone passes away, the funeral 
home comes to our facility to handle the body. But it wasn't safe for 
funeral homes to enter our facility because they didn't have enough 
PPE. So we became the morticians and had to put bodies into body bags.

    Despite my years of training and the love I have for my residents, 
there was nothing I could do to help them. Our residents felt so alone. 
Because we were dressed head to toe in protective gear, they couldn't 
tell who we were. They deserved so much better than what we were able 
to provide with so few staff and resources. As they took their final, 
difficult breath, I hope they knew that we tried our best. I hope they 
knew that we loved them like family. I hope they knew that we didn't 
mean to fail them.

    Between April and June of last year, nursing homes in Rhode Island 
received over $50 million dollars in State and Federal funding in 
response to the COVID-19 crisis. That was on top of a Federal stimulus 
payment of $2,500 per nursing home bed plus $50,000 per facility--
almost $26 million.\1\ Still, Rhode Island has one of the worst records 
in the Nation for COVID-19-related nursing home deaths--six in 10 
COVID-19 deaths were in long-term care settings.\2\ Where did all that 
money go? How was this allowed to happen?
---------------------------------------------------------------------------
    \1\ Crossroads of Care: Repairing Rhode Island's Nursing Homes in 
the Wake of COVID-19, https://drive.google.com/file/d/
1uc3xZ9MxAIubUDTI4fRa8Fkp3D7NzA9c/view.
    \2\ https://www.kff.org/coronavirus-covid-19/issue-brief/state-
covid-19-data-and-policy-
actions/.

    But the pandemic didn't cause the issues we've faced--it only made 
them worse. Rhode island currently ranks 41st in the country for the 
average number of hours nursing home residents receive. The starting 
wage for Rhode Island nursing home workers like me is just $12.34.\3\ I 
am fortunate that I am a member of a union. My co-workers and I were 
able to work together through our union to negotiate higher wages and 
pandemic pay. I felt like I at least had an ability to advocate for 
myself and my residents and shine a light on all the wrongs in our care 
system, which COVID-19 exposed in the most tragic and deadly way. It 
didn't have to be like this.
---------------------------------------------------------------------------
    \3\ https://dlt.ri.gov/documents/pdf/lmi/oesnrcf.pdf.

    If you ask any CNA what their top issues are on the job, it's low 
wages, unsafe staffing, and poor job quality. They are linked together. 
I feel a calling to do this work and care for others. But it is hard to 
do this job when you can't pay your bills, put dinner on the table or 
afford to take your child to the doctor. Some of us have to work two or 
three jobs, just to meet our basic needs. And all this is made harder 
by the fact that because of short staffing, we don't have the time to 
---------------------------------------------------------------------------
spend with residents when they need us.

    One of my hardest days during COVID-19 was when one of my patients 
was slipping away and wanted me to sit at her bedside but I couldn't 
stay because there were twenty other residents who also needed me. This 
is the cycle we need to break.

    Most nursing home workers are women and many of us are women of 
color and immigrants--just like me. Centuries of systemic racism and 
sexism have kept alive the false idea that care workers are unskilled, 
uneducated, and just there to clean up. We've been denied a living wage 
and crucial benefits like affordable health insurance and paid time 
off, and too many of us don't have a union to advocate for ourselves 
and our residents.

    I am doing my part with my union and my coworkers. I was scared to 
get the vaccine--many of us are, we have felt so disposable for so long 
that there is a lack of trust--we didn't want to be test subjects. But 
I did my research, I knew how important it was and how it would keep 
me, my family, and my residents safe. And now I educate others about my 
experience with the vaccine. It is why the union matters and the worker 
voices matter--people in all communities need sources of information 
that feel like they have their best interest at heart.

    Our country's COVID death toll is nearing 600,000. That's more than 
the populations of Baltimore, Atlanta, Miami and nearly three times the 
population of Rhode Island's capital city, Providence.

    Though vaccination rates are going up, giving us all hope that 
soon, the infection rates will slow and the deaths will stop, the 
population of Americans in need of long term care is skyrocketing. This 
pandemic has shown us what happens when we're not prepared to meet the 
demands for care.

    Every shift must be appropriately staffed so residents--our 
Nation's parents, grandparents and loved ones with disabilities--can 
live with dignity and get the care they deserve and depend on. We still 
need PPE. We need paid time off and affordable health care. We need 
livable wages that allow us to provide for our families. And every 
nursing home worker must have a seat at the table to be able to 
negotiate a better life.

    We refuse to be trapped in cycles of poverty and struggle to care 
for our own families. We refuse to continue on with the deadly status 
quo in this industry any longer. Change needs to happen now, and not 
just on the State level. It's why we must raise the minimum wage to at 
least $15 and make sure workers have the ability to join a union to 
advocate for our own futures. Congress has the power to take action and 
raise the standards in all nursing homes in the U.S. so that everyone--
no matter where they are from, where they live or what they do for a 
living--can access high quality long term care provided by a skilled, 
strong workforce that is respected, protected, and paid.

                                 ______
                                 
          Questions Submitted for the Record to Adelina Ramos
                 Questions Submitted by Hon. Ron Wyden
    Question. The Centers for Medicare and Medicaid Services (CMS) 
issued an interim final rule last year that required nursing homes to 
report COVID-19 data to the Centers for Disease Control and Prevention 
on a weekly basis beginning May 17, 2020. These data included COVID-19 
infections, COVID-19 deaths, and the availability of key equipment and 
workers at individual nursing homes. The data have proved to be helpful 
for the public, policy-makers, and industry stakeholders to track the 
pandemic, and related issues, in these care settings. However, to date, 
CMS has not required nursing homes to provide such data prior to May 8, 
2020, despite calls from Senate Democrats to do so. In September 2020, 
the Government Accountability Office (GAO) noted that ``by not 
requiring nursing homes to submit data from the first 4 months of 2020, 
HHS is limiting the usefulness of the data in helping to understand the 
effects of COVID-19 in nursing homes.'' GAO went on to recommend that 
``HHS, in consultation with CMS and CDC, develop a strategy to capture 
more complete data on COVID-19 cases and deaths in nursing homes 
retroactively back to January 1, 2020.''

    Do you support GAO's recommendation? Why or why not? Please briefly 
explain.

    Answer. Yes, it is important for us to be able to look back at the 
beginning of the pandemic to see what went wrong so that we can make 
sure something like this does not happen again. Asking nursing homes to 
provide information about COVID-19 infections, deaths, PPE, and 
staffing for the first 4 months of 2020 will help us to understand the 
timing of the pandemic's entrance into nursing homes and the nature of 
its progression over time. For example, if this data shows problems 
like low staffing levels or inadequate PPE, this means that measures 
need to be put in place ensure adequate staffing and adequate 
availability of PPE.

    Question. Black women and immigrants make up a disproportionate 
share of Certified Nursing Assistants and other nursing home workers--
all of whom have been hit hard by the COVID-19 pandemic. To date, more 
than 550,000 nursing home workers have been infected by COVID-19, and 
at least 1,600 have died. Under normal conditions, these direct care 
workers conduct strenuous work at low wages, and it is not uncommon for 
them to have to work double shifts, work at multiple facilities, or 
take two jobs simply to make ends meet.

    In your testimony, you described how your facility's staffing 
issues were made worse when your coworkers were forced to stay home due 
to COVID-19. The American Rescue Plan Act that President Biden just 
passed provides funding for strike teams, which will provide support in 
the short term for facilities with staffing issues that have been 
worsened by COVID-19. However, this is a short-term solution and will 
not address the ongoing issue of low wages like an increased, national 
minimum wage would.

    How would a $15 minimum wage help nursing home workers, and what 
would the benefit be for patients?

    Answer. A national minimum wage of $15 would benefit all workers, 
including many who work in nursing homes. But from my experience we 
will need an even higher wage to truly address the staffing crisis 
among CNAs. Congress and the administration need to make sure that 
Medicare and Medicaid money going to these nursing homes actually goes 
to front-line staff.

    First, higher wages can serve as an incentive to attract more 
workers to the profession, and higher wages can also work to encourage 
existing nursing home workers to stay in their positions. With more 
workers entering the workforce, and less workers leaving, staffing 
levels could presumably be improved. As I mentioned in my testimony, my 
facility was severely understaffed at times during the pandemic and 
those low staffing levels impacted resident care. Nursing home 
residents, and particularly those that are critically ill, require 
substantial amounts of hands-on care as they may be unable to perform 
essential tasks like eating or getting out of bed by themselves. 
Therefore, it is very important that CNAs are given enough time per 
resident to ensure that resident needs are properly met.

    Higher wages might also make it less likely that nursing home 
workers have to work two or three jobs. The reason why many nursing 
home workers work multiple jobs in different nursing homes to earn the 
money necessary to provide for their families. If nursing home workers 
could earn a living wage by working only one job, a lot more of us 
would choose to only work one job. This would help residents because 
workers would be less likely to travel between facilities every day, 
decreasing the chance that a worker could carry an infection from one 
facility to another.

    In addition to higher wages, nursing home workers also deserve 
pandemic pay or hazard pay during a global pandemic. During a pandemic, 
the job of a nursing home worker becomes more dangerous, and therefore 
deserving of additional pay. Sadly, one of my coworkers at my nursing 
home passed away from COVID-19 and I contracted COVID-19 as well--
although my case was asymptomatic. Pandemic pay or hazard pay should be 
guaranteed for nursing home workers during a pandemic emergency period.

    Question. During the hearing, several Senators and witnesses raised 
the importance of the Federal Government collecting and publishing 
information from individual nursing homes that show the rate of 
vaccinations for residents and staff. Since that time, a bipartisan 
group of senators have sent a letter to the U.S. Department of Health 
and Human Services calling on it to take steps to begin this data 
collection.

    As a front-line nursing home worker, would knowing this type 
information affect whether you would feel comfortable working in a 
given facility?

    Answer. Although I was a bit hesitant to get the vaccine at first, 
I am now fully vaccinated against COVID-19 and I encourage others to 
become vaccinated as well. However, I do understand why some of my 
colleagues are reluctant to be vaccinated. As a workforce of mostly 
women and many people of color, nursing home workers have been 
mistreated over the years, so it is not surprising that there are some 
workers who have yet to be vaccinated. As far as knowing the 
vaccination rate for a particular facility, I do think that information 
is important, but I do not think vaccination rates should be used to 
penalize nursing homes or nursing home workers. The vaccine should be 
made available to nursing home workers at no cost, but it should be 
their choice whether or not to take it.

                                 ______
                                 
                 Questions Submitted by Hon. Todd Young
    Question. As outlined in many of your testimonies, the visiting 
restrictions and isolation necessitated by the COVID-19 pandemic took a 
heavy toll on the emotional and mental health of many nursing home 
residents separated from their family members and other loved ones. 
Fortunately, with increased vaccination and declining COVID-19 deaths, 
many of these restrictions have been lifted.

    While we hope that restrictions of this scale will not be necessary 
again, it is worth examining ways to alleviate the negative emotional 
and mental health effects that isolation may have on nursing home 
residents. The use of technology, for one, has allowed residents to 
interact virtually with family and other loved ones from whom they are 
otherwise separated. Expanded use of telehealth has also helped 
residents access routine health-care services while limiting spread of 
the coronavirus.

    What are some lessons learned from the public health emergency in 
terms of the integration of technology in nursing homes--both in 
helping residents visit virtually with loved ones and in accessing 
health-care services?

    Answer. When it is absolutely necessary to limit visitation in 
nursing homes, video visitation technology can be useful, but its 
utility should not be overstated. Many of our residents have mental 
health conditions like Alzheimer's, and others have extremely limited 
mobility which can limit the benefits of video visitation. And as far 
as caring for residents, telemedicine can be useful, but we cannot 
forget the importance of hands-on care in a face-to-face setting.

    Question. How do you anticipate this type of technology continuing 
to be used beyond the pandemic?

    Answer. I anticipate video visitation and telemedicine to continue 
to be used beyond the pandemic, where appropriate, but I do not see 
these forms of technology taking the place of traditional resident 
care.

                                 ______
                                 
                 Prepared Statement of Hon. Tim Scott, 
                   a U.S. Senator From South Carolina
    For the past year, nursing homes and other senior care providers 
have served on the front lines of our Nation's pandemic response 
efforts, working tirelessly to protect many of the most vulnerable 
Americans from the threats posed by COVID-19. From the earliest days of 
the pandemic, we have understood the heightened risks that this virus 
presents to older Americans, and senior care communities have borne a 
disproportionate burden. As of last month, more than one-third of 
COVID-19-
related deaths in the U.S. were of long-term care facility residents 
and staff. For roughly a dozen States, these individuals have accounted 
for more than half of all pandemic-related fatalities. Fortunately, in 
many States, government officials, health experts, and providers have 
partnered to protect seniors, particularly in these facilities. In 
South Carolina, for instance, Governor McMaster and our health 
department acted quickly and decisively to prioritize nursing homes for 
comprehensive testing, as well as to collect and publish key data 
points on cases and fatalities in extended care facilities.

    Unfortunately, credible evidence suggests that a number of State 
governments have taken actions that have undermined our ability to 
mount a response that can effectively target resources, supports, and 
interventions. By ordering or otherwise encouraging nursing homes to 
accept patients with active COVID-19 infections who were being 
discharged by hospitals, certain States put scores of lives at risk. To 
make matters worse, recent reports suggest that in New York, Governor 
Cuomo's advisors actively intervened to distort data on nursing home 
resident fatalities, downplaying the dire consequences of the 
Governor's actions and tainting crucial data points that informed the 
State's subsequent response efforts. In the case of New York, where 
deaths were initially under-counted by as much as 50 percent, 
inaccurate data reporting denied providers, public health experts, and 
families the clarity and transparency that they deserved.

    We have a responsibility to investigate and ensure accountability 
for State-level actions that have jeopardized American lives and 
compromised the integrity of our pandemic response efforts. I was 
disappointed, earlier this year, when every Senate Democrat voted 
against my proposal to ensure accurate State reporting of nursing home 
resident and staff fatalities related to COVID-19. I was similarly 
disappointed, earlier this month, when Senate Democrats once again 
chose to oppose accountability, this time by voting against an 
amendment I drafted that would have tied a portion of nursing home 
strike team funding to accurate State data reporting. Every Senate 
Republican voted in support of both of these common-sense measures.

    Moving forward, I hope that my Democratic colleagues will join us 
in advancing policies and initiatives that hold States accountable for 
actions that erode public trust and harm the most vulnerable Americans.

                                 ______
                                 
                 Prepared Statement of Hon. Ron Wyden, 
                       a U.S. Senator From Oregon
    The U.S. is now a full year into the COVID-19 pandemic. 
Vaccinations are up. Americans are beginning to feel encouraged. Yet so 
many families--hundreds of thousands spread across the country--are 
unable to share in the sense of uplift about what's to come because 
they are mourning loved ones they've lost.

    Over the last year, more than 175,000 long-term care residents and 
workers, including 130,000 living and working in federally certified 
nursing homes, have died of this terrible disease. They were at the 
center of a collision of mismanagement. In too many nursing homes--even 
before the pandemic--there was chronic understaffing, slipshod plans 
for infection control, and abuse and neglect of vulnerable residents. 
When COVID-19 arrived, the Trump administration came up small by 
withholding data, failing to distribute PPE, and issuing guidance that 
put seniors in harm's way. This was a systemic, nationwide failure, and 
it will be challenging to fix. Members can start by agreeing on basic 
facts.

    First, what's true of the overall population is true in our nursing 
homes too--blacks, Latinos, and Native Americans are suffering the 
worst of COVID-19. A recent study authored by Professor Konetzka, one 
of the witnesses joining the committee today, found that the loss of 
life was more than three times higher in nursing homes with the highest 
proportions of black and Latino residents than in facilities with 
mostly white residents.

    Black Americans and immigrants also make up a disproportionate 
share of nursing home staff. Often they're paid low wages. More than 
half a million of them have had confirmed cases of COVID-19, and 
thousands have died. There's also real concern that COVID-19 will 
continue to circulate among these communities where vaccines aren't as 
readily available, or where uptake is lower.

    These disparities in COVID-19 deaths are the result of generations 
of inequity in society and in health care. Undoing it is going to take 
a lot of hard work by this committee and others.

    Second, the previous administration actively impeded efforts to 
address long-
running problems in nursing homes. You could fill a library with the 
watchdog reports calling public attention to these issues: incidents of 
abuse and neglect, chronic under-staffing, squalid living conditions, 
inadequate emergency preparedness, and 
industry-wide failure when it comes to infection control.

    Instead of addressing these issues, the Trump administration 
dramatically reduced the penalties for failing to meet basic Federal 
protective standards. They went out of their way to undermine any 
chance at real accountability. When States rushed to develop COVID 
policies, some followed Trump administration guidance that encouraged 
nursing homes to accept patients regardless of whether they had tested 
positive for the disease.

    When the pandemic was spreading and nursing homes desperately 
needed PPE, the Trump administration sent out shipments that reportedly 
included loose, unusable gloves, hospital gowns that resembled trash 
bags, and defective masks.

    The Trump administration did not want people to know about what was 
going on in nursing homes. Senator Casey and I spent months pressuring 
and pleading with them to release comprehensive data. The Trump 
administration stonewalled and dithered and delayed before they finally 
began to relent. To this date, there is no reliable data on COVID in 
nursing homes before May 1st of last year because of the Trump 
administration's stonewalling.

    I'll close on one final point. The terrible impact of COVID-19 on 
seniors in long-term care isn't a red State or a blue State issue. It 
is a nationwide tragedy. If you look at the 10 States where nursing 
homes have been hit the hardest, it's five 
Republican-led States and five Democratic-led States.

    So the reality is, long-term care residents in all 50 States were 
incredibly vulnerable to a pandemic like COVID-19 for longstanding 
reasons, but the Trump administration worked harder to protect their 
unscrupulous friends in management than to improve the safety of 
residents themselves.

    The Biden administration is already working to turn things around, 
starting with ramping up vaccinations and creating strike teams of 
highly trained workers who will go into nursing homes and identify 
safety risks to keep residents safe.

    This hearing isn't the first time or the last time that the 
committee will examine nursing home safety. I want to continue working 
with members of this committee, because looking after the well-being of 
America's seniors is right at the heart of our jurisdiction.

                                 ______
                                 

                             Communications

                              ----------                              


        Alzheimer's Association and Alzheimer's Impact Movement
The Alzheimer's Association and Alzheimer's Impact Movement (AIM) 
appreciate the opportunity to submit this statement for the record for 
the Senate Finance Committee hearing entitled ``A National Tragedy: 
COVID-19 in the Nation's Nursing Homes.'' The Association and AIM thank 
the Committee for its continued leadership on issues important to the 
millions of people living with Alzheimer's and other dementia and their 
caregivers. This statement provides an overview on the long-term care 
policy recommendations released by the Association and the impact 
COVID-19 has had on persons living with dementia living in long-term 
care facilities.

Founded in 1980, the Alzheimer's Association is the world's leading 
voluntary health organization in Alzheimer's care, support, and 
research. Our mission is to eliminate Alzheimer's and other dementia 
through the advancement of research; to provide and enhance care and 
support for all affected; and to reduce the risk of dementia through 
the promotion of brain health. AIM is the Association's sister 
organization, working in strategic partnership to make Alzheimer's a 
national priority. Together, the Alzheimer's Association and AIM 
advocate for policies to fight Alzheimer's disease, including increased 
investment in research, improved care and support, and development of 
approaches to reduce the risk of developing dementia.

The COVID-19 pandemic continues to create additional challenges for 
people living with dementia, their families, and caregivers including 
compounding the negative consequences of social isolation that many 
older adults already experience. Social isolation is an issue within 
the aging community as a whole, exacerbated due to the current public 
health crisis, and felt particularly hard in the Alzheimer's and 
dementia community.

Long-term Care, Dementia, and COVID-19

An estimated 6.2 million Americans age 65 and older are living with 
Alzheimer's dementia in 2021. Total payments for all individuals with 
Alzheimer's or other dementias are estimated at $355 billion (not 
including unpaid caregiving) in 2021. Medicare and Medicaid are 
expected to cover $239 billion or 67 percent of the total health care 
and long-term care payments for people with Alzheimer's or other 
dementias. Total payments for health care, long-term care, and hospice 
care for people with Alzheimer's and other dementias are projected to 
increase to more than $1.1 trillion in 2050. These mounting costs 
threaten to bankrupt families, businesses, and our health care system.

At age 80, approximately 75 percent of people with Alzheimer's dementia 
live in a nursing home compared with only 4 percent of the general 
population at age 80. In all, an estimated two-thirds of those who die 
of dementia do so in nursing homes, compared with 20 percent of people 
with cancer and 28 percent of people dying from all other conditions. 
It is critical that all residents of nursing homes, including those in 
skilled nursing facilities and Medicaid nursing facilities, receive 
consistent, high-quality care, especially as people can live for many 
years in these settings.

At least 163,000 residents and employees of nursing homes and other 
long-term care settings have died from COVID-19, representing over 30 
percent of the total death toll in the United States. These communities 
are on the frontlines of the COVID-19 crisis, where 48 percent of 
nursing home residents are living with dementia, and 42 percent of 
residents in residential care facilities have Alzheimer's or another 
dementia. Residents with dementia are particularly susceptible to 
COVID-19 due to their typical age, their significantly increased 
likelihood of coexisting chronic conditions, and the community nature 
of long-term care settings. Across the country these communities, their 
staff, and their residents are experiencing a crisis due to a lack of 
transparency, an inability to access the necessary testing and personal 
protective equipment, incomplete reporting, and more.

To best support individuals living with Alzheimer's and dementia during 
the pandemic, the Alzheimer's Association released a comprehensive set 
of long-term care policy recommendations for federal and state 
lawmakers, Improving the State and Federal Response to COVID-19 in 
Long-Term Care Settings.\1\ These recommendations focus on four areas: 
(1) rapid point-of-care testing, (2) reporting, (3) surge activation, 
and (4) providing support.
---------------------------------------------------------------------------
    \1\ https://www.alz.org/media/HomeOffice/Downloads/Alz-LTC-Policy-
Rec_1.pdf.

These policies are designed to create a strong and decisive response to 
the COVID-19 crisis in all long-term care settings and we were 
heartened to see them in the American Rescue Plan Act of 2021. We thank 
you for including these important provisions and strongly believe these 
provisions are critical to our populations and represent a significant 
step forward in improving their care during this pandemic and beyond.

Long-term Care Recommendation Specifics

We support the inclusion of dedicated funding for testing and tracing 
in nursing homes and assisted living communities. All cases of COVID-19 
in these settings need to be reported immediately and accurately. These 
reports should be updated upon remission, death, transfer, or other 
appropriate status update. With all appropriate privacy safeguards for 
individuals, this reported data should be freely and immediately 
accessible to all down to the facility level. It is crucial that data 
on race and ethnicity are included in this reporting, which will be 
especially important in ensuring targeted support for the entirety of 
the COVID-19 pandemic, and preparedness for potential future pandemics.

As ``hot spots'' occur, they must be dealt with urgently and 
effectively. Any reported COVID-19 cases should trigger careful, 
ongoing monitoring and, if conditions warrant, well-trained and 
equipped strike teams should be deployed to the facility to provide 
needed support until the outbreak is contained and eliminated. All 
nursing homes and assisted living communities must have full access to 
all needed personal protective equipment, testing equipment, training 
and external support to keep them COVID-19-free. We also strongly 
support policies to increase access to televisitation technologies to 
address social isolation in long-term care settings, which can have a 
devastating impact, to ensure people with dementia are able to 
communicate with designated family and friends.

Furthermore, now that the first safe and effective vaccines are 
approved, we urge the continued prioritization of access for Americans 
over the age of 65, particularly those in long-term care settings. This 
is consistent with the Centers for Disease Control and Prevention's 
recommendation that long-term care residents be prioritized for access 
to vaccines, as well as the health care workers caring for some of the 
most vulnerable in our country and who provide an enormous service to 
society as a whole.

Finally, we ask that dedicated funding for home- and community-based 
services continues. People living with dementia make up a large 
proportion of all elderly people who use these important benefits. In 
fact, 31 percent of individuals using adult day services have dementia. 
Access to these services can help people with dementia live in their 
homes longer and improve quality of life for both themselves and their 
caregivers. For example, in-home care services, such as personal care 
services, companion services, or skilled care can allow those living 
with dementia to stay in familiar environments and be of considerable 
assistance to caregivers. Adult day services can provide social 
engagement and assistance with daily activities. Given the demands on 
and responsibilities of caregivers, respite services are also critical 
to their health and well-being, and may allow people with dementia to 
remain in their homes longer.

Nursing Home Legislation

The Alzheimer's Association and AIM have endorsed the Nursing Home 
Reform Modernization Act which would help ensure high-quality care by 
establishing an Advisory Council on Skilled Nursing Facility Rankings 
under Medicare and Nursing Facility Rankings under Medicaid at the 
Department of Health and Human Services (HHS). This new Advisory 
Council would provide HHS with recommendations on how to rank high-
rated and low-rated facilities, with information on those rankings 
posted publicly to the Nursing Home Compare website. Importantly, the 
Special Focus Facility Program would transition to the low-rated 
facility program and Quality Improvement Organizations would work with 
those low-rated facilities to improve their quality of care through on-
site consultation and educational programming. When choosing a facility 
for themselves or their loved ones, families deserve to have all the 
information available in a clear, easily digestible way. We appreciate 
that this bipartisan bill also directs HHS to utilize focus groups and 
consumer testing to ensure these ratings are easily understood by older 
adults, individuals with disabilities, and family caregivers.

Conclusion

The Alzheimer's Association and AIM appreciate the steadfast support of 
the Committee and its continued commitment to advancing policies 
important to the millions of families affected by Alzheimer's and other 
dementia. Thank you, Chairman Wyden and Ranking Member Crapo, for your 
continued commitment to supporting individuals living in nursing homes 
including persons living with Alzheimer's disease and other dementia. 
We look forward to working with the Committee in a bipartisan way to 
advance policies that would help this vulnerable population during the 
COVID-19 pandemic and beyond.

                                 ______
                                 
                      American Geriatrics Society

                       40 Fulton St., 18th Floor

                           New York, NY 10038

                              212-308-1414

The American Geriatrics Society (AGS) would like to thank Chairman 
Wyden, Ranking Member Crapo, and the Senate Finance Committee for their 
attention to addressing the devastating impact of COVID-19 on nursing 
homes and for your ongoing efforts to improve nursing home safety now 
and in the future. The AGS greatly appreciates the opportunity to 
submit this statement and be part of this important conversation. We 
are a national non-profit organization of geriatrics healthcare 
professionals dedicated to improving the health, independence, and 
quality of life of all older Americans. Our 6,000+ members include 
geriatricians, geriatrics nurse practitioners and advanced practice 
nurses, social workers, family practitioners, physician assistants, 
pharmacists, and internists who are pioneers in advanced-
illness care for older individuals, with a focus on championing 
interprofessional teams, eliciting personal care goals, and treating 
older people as whole persons. All of our clinician members have been 
on the frontlines of caring for medically complex older adults during 
the COVID-19 crisis and teaching others to do the same and more for us 
all as we age. That work remains critical to ensuring we all have 
access to high-quality, person-centered, affordable, and age-friendly 
care as we grow older.

The ongoing public health emergency (PHE) has had a disproportionate 
physical and emotional toll on older people, including nursing home and 
other long-term care residents, and the frontline health workers who 
care for them. Older adults and nursing home and long-term care 
residents have been at substantially higher risk for serious 
complications and death compared with other population 
groups.\1\, \2\ As we move forward from the COVID-19 
pandemic, we must address the healthcare workforce shortages and 
improve the public health system to address care needs for the whole of 
our population.
---------------------------------------------------------------------------
    \1\ Centers for Disease Control and Prevention. (2021). People at 
Increased Risk: Older Adults. Available at https://www.cdc.gov/
coronavirus/2019-ncov/need-extra-precautions/older-adults.
html.
    \2\ Centers for Disease Control and Prevention. (2020). People at 
Increased Risk: People Who Live in a Nursing Home or Long-Term Care 
Facility. Available at https://www.cdc.gov/coronavirus/2019-ncov/need-
extra-precautions/people-in-nursing-homes.html.

The AGS urges the Committee to focus on three critical areas where 
attention can help achieve our vision for a United States where we are 
all able to contribute to our communities and maintain our health, 
safety, and independence as we age; and older people have access to 
high-quality, person-centered care informed by geriatrics principles. 
---------------------------------------------------------------------------
These areas include:

    A.  Investing in the direct care workforce, which is the backbone 
of our health and long-term care system.
    B.  Expanding support for the geriatrics health professions 
programs under Title VII: Increasing funding for the geriatrics health 
professions programs and ensuring that these programs are included in 
public health planning efforts.
    C.  Investing in public health: Preparing for future pandemics, 
PHEs, and disasters and ensuring public health planning involve subject 
matter experts and stakeholders.

A. Investing in the Direct Care Workforce

The COVID-19 pandemic significantly exacerbated existing gaps in 
expertise and systemic weaknesses in health care service delivery for 
older Americans particularly for the direct care workforce.\3\ Congress 
must enact federal and state policies that support the largely female 
and women of color direct care workforce by increasing compensation and 
benefits, strengthening training requirements and opportunities, and 
creating advanced roles. Congress must also ensure that all health 
professionals and direct care workers on the frontlines have access to 
paid family, medical, and sick leave.
---------------------------------------------------------------------------
    \3\ American Geriatrics Society. American Geriatrics Society (AGS) 
Policy Brief: COVID-19 and Assisted Living Facilities. J Am Geriatr 
Soc. 2020;68(6):1131-1135. https://doi.org/10.1111/jgs.16510.

Direct care workers are vital to supporting older adults and their 
caregivers at home and in congregate living settings (e.g., long-term 
care and assisted living). They provide hands-on care at the bedside 
that is physically and emotionally demanding to millions of older 
Americans. At present, women account for nearly 90 percent of the 
direct care workforce \4\ and women of color account for 48 percent of 
this workforce in the United States.\5\ Hourly rates are low (often $12 
or less per hour),\6\ and direct care workers often lack paid family 
leave, and other benefits.\7\ Currently, the demand for direct care 
workers exceeds the supply and this gap is only expected to grow. 
Investing in building the direct care workforce should be a priority 
for the United States as a part of investments in the infrastructure 
that is needed to care for us all as we age.
---------------------------------------------------------------------------
    \4\ PHI National. (2020). Direct Care Workers in the United States: 
Key Facts. Available at https://phinational.org/wp-content/uploads/
2020/09/Direct-Care-Workers-in-the-United-States-2020-PHI.pdf.
    \5\ PHI National. (2017). Issue Brief: Racial and Gender 
Disparities Within the Direct Care Workforce: Five Key Findings. 
Available at https://phinational.org/wp-content/uploads/2017/11/Racial-
and-Gender-Disparities-in-DCW-PHI-2017.pdf.
    \6\ Raghu, M. and Tucker, J. National Women's Law Center. (2020). 
Low-paid Women Workers on the Front Lines of COVID-19. Available at 
https://nwlc.org/blog/the-wage-gap-has-made-things-worse-for-women-on-
the-front-lines-of-covid-19/.
    \7\ PHI National. (2021). Caring for the Future: The Power and 
Potential of America's Direct Care Workforce. Available at https://
phinational.org/wp-content/uploads/2021/01/Caring-for-the-Future-2021-
PHI.pdf.
---------------------------------------------------------------------------

B. Expanding Support for the Geriatrics Health Professions Programs

Increasing Funding for the Geriatrics Health Professions Programs
Currently, too few health workers receive adequate, if any, training in 
providing the highly skilled and complex services that make care 
different for older people. Furthermore, staff recruitment and 
retention is particularly difficult due to the medically complex nature 
of care for us all as we age. The Geriatrics Workforce Enhancement 
Programs (GWEPs) and the Geriatrics Academic Career Awards (GACAs) are 
the only federal mechanism for supporting geriatrics health professions 
education and training. The GWEPs educate and engage the broader 
frontline workforce, including family caregivers and direct care 
workers, and focus on opportunities to improve the quality of care 
delivered to older adults. The GACA program develops the next 
generation of innovators to improve care outcomes and care delivery.

Most recently, the GWEPs and GACAs have been on the frontlines of the 
COVID-19 PHE, ensuring clinical and educational training can enhance 
their communities' response to the pandemic and its impacts on older 
adults. The GWEPs and the GACAs are the only federal programs that 
focus on training the workforce to care for older Americans and 
investing in these programs is imperative to maintaining the health and 
quality of life for us all as we age. At minimum, Congress should 
increase annual appropriations to $51 million given the essential role 
awardees play in their states.
Ensuring that Planning Bodies Include the GWEPs and GACAs in Public 
        Health Planning Efforts
These programs are also playing a key role in public health planning 
efforts. The GWEPs and GACAs have been an asset for states especially 
as many states and localities grapple with the rollout of the COVID-19 
vaccine and address vaccine hesitancy. GWEPs have been staffing call 
lines to assist older adults to register for the vaccine, advising 
local authorities on making the sign-up websites age-friendly, and 
working with health systems in the rollout of vaccines and outreach to 
vulnerable and hard-to-reach populations (e.g., homebound older 
Americans and Americans with disabilities). Through Project ECHO, a 
telelearning and telementoring program, they have been working with 
nursing homes to train staff on how to use personal protective 
equipment (PPE) and on infection prevention protocols. This effort is 
consistent with CMS's overall priority to reduce COVID-19 infections in 
nursing homes and keep residents and staff safe during the pandemic. 
Looking ahead, these programs will be critical in providing assistance 
for proactive public health planning with their geriatrics expertise 
and knowledge of long-term care and can help ensure states and local 
governments have improved plans for older adults in disaster 
preparedness for future pandemics and natural disasters. To assume 
these roles, there would need to be additional investments by Congress 
in both programs to ensure that states have access to the expertise of 
GWEPs and GACAs. One avenue for ensuring that access is for the Health 
Resources and Services Administration (HRSA) to include attention to 
expertise in geriatrics and gerontology in its planning for rebuilding 
the public health workforce as called for in the American Rescue Plan 
Act of 2021. One way to accomplish that objective is to increase 
funding to the GWEP and GACA programs with the specific goal of 
ensuring that all states have access to the geriatrics education and 
training that these programs provide to the healthcare workforce.

The reality is that our current healthcare workforce is ill-prepared to 
care for older adults given the paucity of required training in 
geriatrics across disciplines. Although AGS does not specifically track 
the public health workforce, we believe it is critical that investments 
be made in ensuring that this workforce understand the needs of older 
Americans so that we can ensure that agencies and organizations focused 
on the health of the public are meeting the needs of this large and 
growing demographic group. With funding from the John A. Hartford 
Foundation, Inc., the Trust for America's Health is exploring the 
public health needs of older Americans with the goal of ensuring that 
we are developing age-friendly public health systems.\8\ Given their 
focus on developing age-friendly health systems, focus on transforming 
primary care, and partnerships with community-based organizations, the 
GWEPs are well-positioned to assume a greater role ensuring that as we 
build up our public health workforce we are doing so in a way that 
supports an age-friendly public health system.
---------------------------------------------------------------------------
    \8\ Trust for America's Health. (2018). Creating an Age-Friendly 
Public Health System: Challenges, Opportunities, and Next Steps. 
Available at https://www.tfah.org/wp-content/uploads/2018/09/
Age_Friendly_Public_Health_Convening_Report_FINAL__1___1_.pdf.
---------------------------------------------------------------------------

C. Investing in Public Health

Preparing for Future Pandemics, PHEs, and Disasters
A critical area of focus should be to ensure we have plans for how to 
protect the health and safety of all Americans in the event of a future 
pandemic, PHE, or natural disaster. This should include assurance that 
Crisis Standards of Care that dictate allocation of scarce resources do 
not include discriminatory policies that are based on age alone.\9\ The 
current COVID-19 PHE underscored the gaps in our planning specific to 
older adults which, as in natural disasters like Hurricane Katrina, 
resulted in the pandemic having a disproportionate impact on older 
Americans, particularly older Americans of color. It is critically 
important that the federal government review and revise PHE and 
disaster guidance related to this population to provide guidance for 
state and local planning.
---------------------------------------------------------------------------
    \9\ Farrell T.W., et al. AGS position statement: Resource 
allocation strategies in the COVID-19 era and beyond. J Am Geriatr Soc. 
2020;68(6):1143-1149. https://doi.org/10.1111/jgs.16537.
---------------------------------------------------------------------------
Ensuring Public Health Planning Involves Subject Matter Experts and 
        Stakeholders
Public health planning will necessitate coordination with several 
important stakeholders and across several different priorities.\10\ We 
recommend that public health planning involve subject matter experts 
and stakeholders including:
---------------------------------------------------------------------------
    \10\ American Geriatrics Society. American Geriatrics Society (AGS) 
Policy Brief: COVID-19 and Nursing Homes. J Am Geriatr Soc. 
2020;68(5):908-911. https://doi.org/10.1111/jgs.16477.

    a.  Geriatrics health professionals should be recruited to serve on 
pandemic and disaster response and planning teams, given their 
expertise in caring for older people with medical complexity or 
advanced illness, leading interprofessional collaboration, implementing 
knowledge of long-term care across settings and sites, and leading 
advance care planning. This unique skillset is essential for community-
---------------------------------------------------------------------------
level planning.

    b.  Nursing homes and other long-term care settings leadership 
teams (e.g., administrators, medical directors, and directors of 
nursing) are vital for planning how resources can be best deployed 
during a pandemic. These teams have expertise in allocating resources 
within their own facilities; developing community-wide plans in 
collaboration with acute care hospitals and other post-acute care 
institutions in their communities; and building understanding of 
staffing needs, as well as federal and state regulations.

    c.  Hospice and palliative care experts should be recruited to 
serve as members of pandemic planning teams, given the need to ensure 
hospitals and other facilities have access to expertise in advance care 
planning, symptom management, and end-of-life care, where available.

We encourage you to consider focusing on the three critical areas while 
examining COVID-19 in the nation's nursing homes.

Thank you again for the opportunity to submit this statement and for 
your attention to these concerns. The AGS looks forward to continuing 
to work closely with the Committee as you work to improve the lives of 
all Americans.

                                 ______
                                 
                    Letter Submitted by Dan Arbeeny
The Honorable Ron Wyden
Chair
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20510-6200

        RE: March 17th Hearing ``A National Tragedy: COVID-19 in the 
        Nation's Nursing Homes''

    Chairman Wyden and Ranking Member Crapo:

    My name is Dan Arbeeny and I live in Brooklyn, NY. In one week in 
April 2020, we had four family members die of COVID: my father, my 
uncle and two close cousins. Of the four, only one was counted as a 
COVID death.

    Thank you very much for scheduling this hearing on the impact of 
COVID-19 on nursing homes and continuing the Committee's commendable 
policy of allowing members of the public to supplement the hearing 
record with additional and, in our case, personal family experience.

    The scope of this nursing home debacle has already been well 
described in the hearing testimony of the Government Accountability 
Office (GAO) which pointed out that while ``the nation's 1.4 million 
nursing home residents are a small share of the total U.S. population 
(less than 1 percent), they comprise nearly 30 percent of COVID-19 
deaths reported by the Centers for Disease Control and Prevention 
(CDC).'' In actual numbers, this amounts to more than 174,000 
individuals with the numbers still rising.

    Our experience in New York, for which I claim no official role but 
that of a person who has been outspoken and willing to respond to press 
inquiries about how the situation in our State was made so much worse 
than it had to be due to the actions of Governor Cuomo and virtually 
all other aspects of the state government. I refer primarily to the 
Governor's Directive of March 25, 2020 compelling the State's nursing 
homes to accept COVID-19 patients.

    By no means do I intend to imply that the State of New York's 
nursing homes were innocent parties in this series of reckless and 
wrongful actions contributing to the death of my father, other members 
of our family and thousands of other New Yorkers with whom I have been 
in close contact now for over a year in time. We have reluctantly 
become the 100,000 New York State COVID-19 nursing home orphans.

    My family has lived on the same block in Brooklyn, New York for 
five generations. It is a wonderful heritage we were given, but more 
importantly, it is where my family has deep community roots. My father 
was a vivacious man of 88 years, still working and driving with a very 
sharp mind and quick smile. He sat on the stoop of the house always 
offering a smile, a greeting and keeping an eye-out for neighborhood 
happenings.

    Right after Christmas my father took ill and recovered, but a 
series of illnesses, non-life threatening, happened that required he be 
in and out of the hospital and then to a nursing home in our immediate 
neighborhood called the Cobble Hill Health Center (CHHC). In short, my 
Dad was doing as best he could and was COVID-free up until the time of 
the Governor's disastrous March 25th Directive.

    It was the CHHC which told us about the Directive and that they 
were trying to persuade governor's office not to force them to take 
COVID patients. Unfortunately, Governor Cuomo and the State Health 
commissioner ignored their pleas. It then took us many days to move him 
back home and it was during that time in CHHC that he got a low-grade 
fever. Despite 24-hour care, a week later he developed congestion and 
his doctor ordered a COVID test. We tested him on Monday, April 20, 
2020 at 1:00pm and 12 hours later he was dead and the COVID test came 
back positive afterwards.

    Even as non-medical personnel, we knew it was senseless for the 
State government to exercise the fullness of its powers to compel 
contagious patients to the residences where the weakest and most 
vulnerable were confined. What could they possibly have been thinking 
and why were there not more nursing homes and their professional 
associations speaking out against this ill-considered action? Instead, 
the response of the State Legislature was to roll over at the 
Governor's request and grant purported immunity to all the players in 
this dereliction of duty.

    Five days after the governor signed his March 25th Directive, the 
USS Comfort and the Javits Center hospital came online giving NYC and 
the surrounding area an additional 2,000 hospital beds. The Governor 
did not use those facilities for patients and the general utilization 
was minimal. The governor also added more regulations with regard to 
the use of the Javits Center making it almost impossible to send an 
elderly patient there.

    Six days after the governor signed his March 25th order, the 
Samaritans Purse field hospital in Central Park opened with 68 beds. 
Again, for reasons which remain inexplicable, the Governor refused to 
use this facility for COVID patients.

    At this point we had two choices before us, give in to the grief 
and anger or focus on reaching out to others in order to bring the 
truth to life. We started by organizing similarly situated individuals 
and doing fundraising events for Personal Protective Equipment for CHHC 
and other front-line workers as well as our local police precinct.

    At the same time, the media, to its credit, began to focus on CHHC 
because it was reporting so many COVID deaths as part of the State 
collection process. As it turned out, the reason for this was that CHHC 
was the only nursing home that properly reported the number of possible 
covid deaths. To the best we understood it, every other one of the 627 
nursing homes significantly underreported and, of course, it was 
subsequently admitted that the State itself was once again the prime 
mover in this well-orchestrated cover-up.

    Being so closely involved with CHHC, I spoke with many of these 
reporters covering this story and it was across the full spectrum of 
news outlets including News1, CNN, CBS, ABC, WSJ, Fox, AP, and many 
others. There were so many that my brother Peter and I had to divide 
them up in order to get out the truth of what was really happening. We 
took hours to explain that CHHC was not a party at fault but that it 
was the system at large and Governor Cuomo in particular who was 
understating the New York death toll by midsummer at 6,500 while we had 
been saying since April 2020 in over 50+ interviews including one with 
Jake Tapper on CNN that the true number is more like 12,000 to 15,000 
deaths.

    When the news subsequently came out that the governor was writing a 
book about his ``leadership'' during the COVID pandemic we knew it was 
time to step up our efforts to get the actual truth out to all the 
aggrieving families and other residents of New York State so they could 
safeguard themselves against the March 25th Directive. We were also 
hoping that the appointed and elected officials in New York as well as 
the federal government would begin to take note.

    On October, 18, 2020, our growing but still informal organization 
hosted a Mock Funeral for Governor Cuomo's so-called ``Leadership and 
Integrity'' which focused on two simple points. We asked for an apology 
and that there be full admission of the true number of our loved ones 
who had died in nursing homes. There was abundant press coverage which 
we again appreciated in terms of trying to keep our cause alive.

    We watched aghast as the Governor received an Emmy Award for what 
we now know was a disastrous policy, a cynical effort to cloak it 
through state-granted immunity and then a program of lying to cover it 
up as long as possible. Based on what we now know, every statistic the 
government used was misleading; rather than using facts to point us to 
the truth, the ``guardians of the public interest'' used their offices 
to point us away from the truth.

    Finally, on January 28, 2021 the New York State Attorney General 
belatedly announced what was considered a ``bombshell'' report 
confirming that there had been a significant undercount of the number 
of COVID deaths in New York nursing homes. That was followed very 
quickly by the governor and State Department of Health losing in its 
legal effort over reporting the COVID death data to the Empire Center 
for Public Policy, an independent, non-partisan, non-profit think tank 
based in Albany, NY. We likewise want to commend Judge Kimberly 
O'Connor for her fortitude in that case.

    Most recently and inevitably, the Secretary (Chief of Staff) to the 
Governor, Mellisa DeRosa admitted at a private meeting what we had been 
saying for almost a year, that the State hid the true number of deaths. 
That meeting soon became public as did the next stage of the Governor's 
campaign to blame everyone else.

    At this point, speaking for myself and I believe almost every other 
family in this situation, we have accomplished the goal of getting out 
the truth. But no one in the public or private sector is admitting 
their culpability for the death, distress, pain, and suffering they 
have caused and concealed. We respectfully request the assistance of 
this Committee in continuing its oversight and investigation of New 
York State and every other state which pursued a similar program of 
confining the COVID-ill to the most susceptible of the still healthy 
elderly residing in Medicaid-funded nursing homes.

CONCLUSION

    These are the facts as we see them from the ground:

        The Governor forced 9,000 COVID-positive patients into nursing 
homes in New York State;
        There are 627 nursing homes in the State of New York but only 
one spoke the truth;
        The Governor and State Legislature wrongly sought to immunize 
the medical community, hospitals, nursing homes and their associated 
trade groups, management consultants, and other service providers that 
assisted these companies in partnership with Governor Cuomo, the State 
Department of Health and other State offices and employees;
        The Governor and other State officials and private parties 
knowingly and now admittedly lied to the public and impugned the 
character of persons seeking to tell the truth.

    Crown Publishing Group has just announced that it has ceased 
promotions of the Governor's book entitled ``American Crisis: 
Leadership Lessons from the COVID-19 Pandemic,'' and that there were no 
plans to reprint the book or to reissue it in paperback. This is an 
important first step but wholly inadequate still as the proper remedy 
is for the publisher to disgorge all past and future proceeds and to 
rescind the advances and any other payments made to the Cuomo in 
connection with a publishing enterprise built entirely on false 
pretenses. These funds should then be directed to a charitable fund in 
order to help defray the burial expenses of the victims of this series 
of unconscionable activities.

    In addition, the Academy of Television Arts and Sciences needs to 
withdraw the 2020 International Emmy Founders Award which it 
inappropriately awarded to Governor Cuomo last November.

    Thank you for the opportunity to submit these views.

    cc: The Hon. Charles Schumer
       The Hon. Kirsten Gillibrand

                                 ______
                                 
                  Statement Submitted by Marla Carter

   Green River Area Development District (GRADD) Ombudsman Advisory 
                        Council, Consumer Member

    Faithful Friends Nursing Home Ministry leader, Pleasant Valley 
                            Community Church

Daughter-in-law of, friend to, advocate for residents in long-term care 
                                 (LTC)

After watching the full committee hearing on March 17th, I felt 
compelled to respond; first of all, with my deepest gratitude for the 
issues that were discussed and the concerns that were raised, and 
secondly to share my direct experiences that confirm much of what was 
discussed. Having been volunteering in LTC for almost 3 years now, I 
will tell you that every harrowing story and every shocking fact shared 
with your committee is consistent with what I have witnessed. The long-
term care system in this country has been broken for quite some time, 
and the pandemic has simply forced us to look in the mirror and finally 
see the way we are caring for the elderly and disabled residents of 
LTC.

My mother-in-law is a resident of a Genesis owned facility here in 
Owensboro, Kentucky. Before the pandemic, our church had adopted this 
facility and we were inside the facility weekly; we held Sunday school 
classes, did crafts with residents, sang with residents, prayed with 
them, visited with them, and often advocated for them. 60-80% of 
nursing home residents never receive a single visitor; therefore, for 
many residents, we became their family.

Before the pandemic, it was not unusual for us to hear residents say, 
with regards to their care, ``I pushed my call button but no one 
came,'' or ``I keep telling them I need to go to the doctor but they 
won't make me an appointment,'' or ``they lost my favorite blanket even 
though it had my name on it,'' or ``I'm out of pull-ups in my size so 
they told me I have to wear a different size.''

Since the pandemic, communication has become very difficult. The 
facility does not have in-room land line phones, and only a handful of 
residents have personal cell phones. Most residents must go to the 
nurses station to use the phone, which is hardly private and very 
discouraged during the pandemic due to infection control. Even still, 
here are the kinds of phone calls we've gotten now:

      ``There's no one to do the laundry, and I'm out of underwear, so 
they put me in pull-ups.''
      ``It's so hot in my room but they won't let me have a fan 
because it will blow the virus around.''
      ``We can't have showers because the steam makes the virus more 
contagious. I haven't had a shower or bed bath in weeks and I smell 
myself, so I know other people smell me too. I'm embarrassed.''
      ``I asked for a drink and they told me to get it myself.''
      ``Help! I'm on the toilet and I pushed the call button but no 
one has come and I've been sitting here for an hour.''
      ``Help! They're killing me! No one will help me. Please call my 
priest and tell him I'm sorry for every sin I ever committed.''
      ``I had an accident . . . I couldn't get to the toilet in time 
so I have diarrhea all over myself. I asked for help cleaning up but 
the staff told me they didn't have time because they were passing out 
trays.''
      ``I haven't had my medicine in five days. They ordered the 
refill but it hasn't come in yet.''
      ``I like giving my friends snacks but the staff yells at me and 
says I have to stay in my room all the time. I feel like I'm in a 
communist country.''
      ``The staff told me I'm a troublemaker. Do you think I'm a 
troublemaker?''
      ``The traveling nurse gave me the wrong medicine and I had a 
really upset stomach. She told me not to tell you.''
      ``I told the staff that my roommate had a fever and was sick but 
they told me to mind my own business.''

Keep in mind that we have an excellent relationship with this facility. 
The administrator has been very supportive and tries very hard to 
ensure residents are cared for with compassion and dignity. But she can 
only work with what she's given by corporate--low wages and the 
inability to hire more staff--and she can't be there all the time.

Even in the midst of the pandemic, when they were receiving more 
federal and state funds, I did not see an impact on patient care. For 
example, this facility received nearly the maximum amount of civil 
monetary penalty funds for improving virtual communication in the 
summer of 2020. It's unclear to me exactly what that money was spent 
on, though presumably it was spent on new iPads. My experience, though, 
was that staff didn't know how to set up the iPads/Facetime and even 
when they figured it out, there were only 4 for the building and they 
had to be shared; residents had to wait for a staff person to bring 
them an iPad and help them with it. Some residents used them to watch 
religious services online, and a few virtual ``visits'' were scheduled 
for Mother's Day and birthdays.

A few cell phones were purchased so that each unit would have a phone 
that could be taken to resident rooms instead of them having to use the 
phone at the nurses station. However, those phones quickly got lost.

The activities director went above and beyond to try to keep residents 
entertained, though she was limited with her resources as well. Here 
are all the things our church donated to the facility because they 
couldn't buy them:

      Shepherd's hooks (to hang bird feeders outside residents' 
windows);
      5 CD players (because each wing had to have its own because they 
weren't allowed to carry their one CD player wing to wing due to 
infection control);
      Craft supplies: construction paper, glue, markers, crayons, old 
magazines, paint, cereal boxes, buttons, wrapping paper, note cards, 
pumpkins; and
      Misc items: 10 sets of drum sticks, 10 large stability balls, 10 
laundry baskets, printable games, puzzles, activity pages, Scripture 
hand outs, Bibles, devotionals, library books, CDs, DVDs, VHS tapes, 
television

Other items we have donated:

      Clothing, shoes, socks;
      Gift bags for all residents containing snacks, puzzle books, 
markers, tumblers, lotion, shampoo, hairbrush, tissues, soft candy, 
pens, notepads (twice yearly); and
      In the past year, our church spent $5,000 on things for this 
facility--some of that money went for treats for the staff to encourage 
them. This figure would be much higher if we factored in what folks 
from our church donated--hundreds of dollars in Christmas gifts and 
toiletries.

While you would expect that a facility that charges nearly $8,000/month 
could supply the most basic of things, we are constantly amazed at how 
many residents are impoverished and needy. We have brought clothing to 
residents who had only one change of clothes and pajamas to residents 
who only had a hospital gown. Residents often run out of tissues, pull 
ups, and personal hygiene items. (Most residents are on Medicaid and 
thus only receive a $30 allowance each month. Their $30 is all they 
have for things like haircuts, snacks, clothing, anything ``extra.'')

You would also expect that such a facility would have a doctor on site 
at all times; after all, this is a skilled nursing facility that cares 
for some very acutely ill residents. However, there is only a nurse 
practitioner on site Monday-Friday. The ``medical director'' is a local 
physician who works on the side to ``oversee'' the medical care the 
nurse practitioner is providing. He checks in periodically and comes in 
a few times a month to check over the charts. He is listed as my 
mother-in-law's primary care physician, yet when I have a question 
regarding her care, I cannot call him on the phone to discuss her care.

Another thing you might expect from such a facility is that they would 
provide transportation for residents to and from doctor's appointments 
or even for ``fun'' outings. No. This facility does not have a vehicle/
bus/van. When residents leave to go to a medical appointment, they must 
ride on the local GRITS bus (Green River Intra-County Transit System), 
which is a free or low-cost public transportation service- free for 
persons receiving Medicaid and low cost to the general public.

One terrible example of facilities relying on this service involved a 
92 year-old ward of the state who was being transferred from one 
skilled nursing facility to another in mid-July. She was transferred on 
the GRITS bus, wearing a black sweat suit and no shoes (socks only) 
with none of her belongings except her Bible. It was weeks before she 
had any of her belongings delivered to her because each facility 
claimed not to know which one was responsible for transporting her 
things, and both used the excuse that they did not have a facility 
vehicle. Additionally, during the pandemic, facilities are still 
relying on this public transportation--residents that had to leave 
regularly for dialysis or other regular appointments were not allowed 
to ride in a family member's car--they had to use the GRITS bus, though 
their family member was allowed to meet them at the appointment. 
Illogical!

We have gotten creative during the pandemic to find ways to continue to 
help the residents and the facility, but we dearly miss the residents 
and they miss us. I have asked corporate repeatedly to allow us to 
continue to volunteer, even outdoors if preferable. This facility, like 
so many others, has struggled to maintain its staff. They've had a 
great deal of turnover and are always in need of more staff. They did 
hire some emergency ``unit aide'' people, who were untrained but came 
in for a few months to help with basic, non-medical tasks. These are 
things we could have been doing for free! Before the pandemic, we were 
in many ways, ``staff extenders.'' Here are some things we did:

      Wheeled residents to the dining hall;
      Sat with residents and encouraged them eat;
      Helped them get a different food choice if they didn't like what 
was served;
      Got them water/drinks (with staff direction- we knew who had 
fluid restrictions, etc);
      Helped locate lost items in the laundry room;
      Helped write names in/on resident belongings;
      Helped locate lost items in rooms (glasses, dentures, remote 
controls, etc);
      Helped fix TVs, phones, radios, etc.;
      Went to the store for residents;
      Assisted with holiday parties and crafts;
      Scheduled extra fun activities for residents (for example we had 
a sweet girl from our church who has no arms come in and paint for the 
residents with her feet--they loved her!!);
      Held weekly Sunday school classes for residents;
      Helped residents make phone calls;
      Helped re-direct residents who were wandering; and
      Sat with residents who were upset, talked with them.

These are all very important tasks that the staff simply does not have 
time to do because they are stretched too thin. This summer, when 
outdoor visits began to be allowed, we offered to come assist with 
screenings at the door and supervising the visits outside, but were 
told no. As of today, we are still not allowed inside. Our ministry 
team of volunteers has been vaccinated and so have over 90% of the 
residents, while only 50% of staff have been vaccinated. We would like 
to come inside and help!! If untrained employees could be hired for 
extra help in the middle of the pandemic, why can't we now enter and 
help. We can go through the same screenings as staff and be trained in 
infection control practices. Our services are free and contribute 
greatly to residents' quality of life! So why would corporate not allow 
us inside to help at a time when they cannot keep staff?

When we first started visiting my mother-in-law and other residents in 
the nursing home, I was shocked by the conditions. Since then, I've 
done much reading about Medicare certified facilities, the care they 
provide, and the great expense they are to the taxpayer and the 
government. For example:

      ``The vast majority of nursing homes reap substantial funding 
from Medicare and Medicaid in exchange for the promise of providing 
quality care to their patients. In fact, a 2015 CMS report found that, 
in 2014, of the 15.634 nursing homes across the US, 92.2% (14,407) were 
dually certified to receive both Medicare and Medicaid payments. In 
other words, federal government taxpayer funding pays for most nursing 
home care. And the truth is that these nursing home corporations rely 
upon this steady course of income--government payments--to generate 
profit. Many, in fact, generate very substantial profits from it.''
      In 2009 alone, one out of every four claims submitted by the US 
nursing home industry was erroneous, resulting in $1.5 billion worth of 
unjustified payments from Medicare.
      A 2015 article entitled ``Nursing Home Care Industry Is a Solid 
Investment,'' pointed out the virtues of investing in the nursing home 
industry: ``Profits are staggering, and the nursing home companies have 
a long time of add-on sales for supplemental services through 
subsidiaries they control.'' (Dr. Harold Goldmier, investment 
strategist, 2015)
      The modern American nursing home grew out of the 19th-century 
almshouse, a kind of public, charitable organization that was set up to 
help the ``worthy poor'' (originally, widows of good social standing 
who had fallen into destitution). The almshouse system expanded until 
the 1930s, when officials at the United States Social Security Board 
began to worry about the ``increasing dependency'' of ``the aged''; 
they feared that old people would bankrupt the country with their 
expensive infirmities. They made efforts to shut the facilities down, 
and they proposed that the government start a small pension, what would 
become Social Security benefits.

       In place of the almshouses came pay-to-stay ``rest homes'' and, 
later, more medically staffed nursing homes, all competing in a private 
marketplace for elder care. By 2000, nursing homes were a $100 billion 
business, and the little mom and pop shops that had once dominated the 
industry were being fused together and swallowed up into larger 
entities. For a time, it seemed like nothing could stop the growth. It 
didn't matter when, in the early 2000s, five of the country's top-ten 
nursing-home chains entered into Chapter 11 bankruptcy proceedings 
after undertaking a string of heavily debt-financed mergers and 
acquisitions. The companies were restructured, and sometimes rebranded, 
and then continued on their way. Today, around 70 percent of nursing 
homes are for-profit, and more than half are affiliated with corporate 
chains.

       All the while, nursing-home chains continued to get bigger, 
until just five companies owned more than 10 percent of the country's 
1.7 million licensed nursing home beds. Private equity also entered the 
sector, buying up four of the ten largest for-profit nursing homes. 
``There's essentially unlimited consumer demand as the baby boomers 
age,'' Ronald E. Silva, president of Fillmore Capital Partners, told 
The New York Times in 2007, after paying $1.8 billion to purchase a 
large nursing-home chain called Beverly Enterprises Inc. ``I've never 
seen a surer bet.'' These new ownership groups changed things in ways 
that people who lived in them could feel. Earlier this year, a Wharton 
School--New York University--University of Chicago research team found 
``robust evidence'' that private-equity buyouts lead to ``declines in 
patient health and compliance with care standards.'' When nursing homes 
are bought by private-equity groups, the team concluded, frontline 
nursing staff are cut, and residents are more likely to be 
hospitalized.

       But the most consequential change may have happened within the 
for-profit companies themselves. It all started, most undramatically, 
with a 2003 academic article in The Journal of Health Law. In 
``Protecting Nursing Home Companies: Limiting Liability Through 
Corporate Restructuring,'' its authors--two health-care lawyers--made 
note of two financial threats to nursing-home operators: lawsuits by 
nursing-home residents (for, say, negligence) and efforts by the 
government to recoup overpayments (for, say, false claims on Medicare 
billings). The solution, the authors suggested, was in restructuring. 
Specifically, nursing homes should split up into separate limited-
liability corporations, one for real estate and one for operations. 
This new structure, they wrote, would keep assets safe from litigious 
family members and retributive bureaucrats. It would also attract money 
from real-estate investors who were keen on nursing homes but wary of 
the liability risks. By 2008, the top-ten companies had all split 
themselves into real estate and operations LLCs.

       Then many companies went further, creating networks of sub-
companies called ``related parties'' that could trade and transact with 
one another. What had once been a nursing home became a corporate 
cluster, including separate entities for real estate, insurance, 
management, consulting, medical supplies, hospice, therapy, private 
ambulances, and pharmacy services. By 2017, three-quarters of nursing 
homes did business with related parties, according to a study by Kaiser 
Health News. There was nothing inherently wrong, and certainly nothing 
illegal, about these increasingly complex formulations. The owners said 
that they were only creating a vertical supply chain for eldercare. By 
2015, nursing homes were spending $11 billion a year on contracts with 
related parties.

       But the structure had an additional benefit that the authors of 
the article had not pointed out: It allowed companies to siphon profits 
out of their nursing homes through sometimes exorbitantly overpriced 
transactions with their sister companies. Instead of hiring salaried 
managers to oversee a facility, a nursing home could now contract with 
expensive related-party management corporations and consultancies. 
Instead of owning the land around a nursing home, a company could lease 
it from a related-party real-estate business, sometimes at a higher-
than-market rate. In this way, a nursing home could appear, on its 
accounting sheets, to be operating on slim margins, or even at a loss, 
but only because that loss was offsetting gains within the same 
company.

       ``No one begrudges a company for making profits,'' Dr. Michael 
Wasserman, president of the California Association of Long-Term Care 
Medicine, told me. ``This is capitalism. This is America.'' The issue, 
he said, is that doctors and nurses are pressed to cut costs while 
related parties are getting rich. ``If the real-estate entity is making 
significant profits and the operation is break-even, then there's a 
problem. I would compare today's nursing-home real-estate owners to 
slumlords.'' This excerpt is from an article that appeared here: 
https://story.californiasunday.com/covid-life-care-center-kirkland-
washington?fbclid=Iw
AR24x0cPBI-v3I37CIJpKr0R729Ew9OZ_AfOGUnjE7wHrB-4pLd18r00YIQ.

      A 2014 report by the Office of the Inspector General of the 
Department of Health and Human Services about adverse events in skilled 
nursing facilities found that one in three patients who stay in a 
nursing home will suffer harm or injury within the first 35 days as a 
result of the care they receive. The report also found that most of 
these incidents are ``clearly or likely preventable,'' and attributed 
much of the preventable harm to ``substandard treatment, inadequate 
resident monitoring, and failure or delay of necessary care.''--
Levinson, Office of Inspector General, 2014

       In the above report, 66% of these harmful events were due to 
preventable medication errors. The report further found an estimated 
7,203 hospitalizations for medication events, which on average, cost an 
estimated $8,372. The estimated total spending related to 
hospitalizations for medication events was an estimated $57,729,935--
just for the month of August 2011. (That is NOT a typo!)

      The nursing home setting is a significant risk factor for sexual 
abuse. A study of elder sexual abuse in Virginia from 1996 through 2001 
which researched sexual abuse in both institutional and residential 
settings found that nearly three-quarters of all sexual abuse occurred 
in nursing homes. (Teaster and Roberto, 2005) In other words, an 
elderly person is in more danger in a nursing home than on the streets 
of a typical U.S. city.
      Pressure sores have long been established as an indicator or 
substandard care. CMS identifies stages III and IV pressure sores as 
being one of eight preventable conditions. In 2004, more than one in 
ten nursing home residents had a pressure sore (NCHS, Park-Lee & 
Caffrey). The total annual cost for treating pressure sores in the US 
is $11 billion (Institute for Healthcare Improvement, 2007).
      No doubt, the patients and their families are the primary 
victims, but clearly, lower-level nursing home staff are victimized by 
the industry's obsession with profits as well. As if being stressed, 
overworked, and forced by circumstances to mistreat patients weren't 
enough, the median annual wage of nursing aides and orderlies working 
in nursing homes is $24,7000 and $19,950 to $22,580 respectively (U.S. 
Bureau of Labor Statistics, 2016-2017). Effectively, the working poor, 
who are themselves among the most vulnerable in our society, are the 
ones taking care of elderly, vulnerable patients. Each is being taken 
advantage of by the nursing home industry.--Abuses and Excuses: How to 
Hold Bad Nursing Homes Accountable, by Jeffrey Powless.

In my humble opinion, not only are many nursing homes committing 
Medicare/
Medicaid fraud by failing to provide the services for which they are 
receiving federal funds, but also by then receiving more money from the 
government and the taxpayers to take care of the additional health 
problems that their negligence has created. It's akin to double 
billing!

It is my firm belief that most all of the issues within the nation's 
nursing homes can be boiled down to staffing. They don't hire enough 
and they don't pay enough. However, providers are going to tell you 
they can't find employees, or that they need more Medicare/Medicaid 
reimbursements in order to hire more and pay more. I just don't believe 
that's true. I think the way they have been allowed to structure their 
corporations with private equity firms controlling the various 
intertwined entities of real estate, vendors, and goods is the real 
problem. I have seen non-profit facilities and the difference in care 
they provide is remarkable.

If you would like further reading on these issues, here are some 
resources I have found helpful:

https://www.amazon.com/Abuses-Excuses-Nursing-Homes-Accountable-ebook/
dp/B075P8DS4V

https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/0805095152

https://story.californiasunday.com/covid-life-care-center-kirkland-
washington?fbclid
=IwAR24x0cPBI-v3I37CIJpKr0R729Ew9OZ_AfOGUnjE7wHrB-4pLd18r00YIQ

https://www.sentinel-echo.com/news/nursing-homes-had-problems-
controlling-infections-before-covid-19/article_7ae9804e-8e1b-11ea-8c5a-
a36127b9d3fb.html

https://www.marketwatch.com/story/covid-19-devastated-nursing-homes-
here-are-safer-more-cost-effective-options-11602245129

https://www.wsws.org/en/articles/2020/04/27/nur2-a27.html

https://nurse.org/articles/nurse-staffing-unsafe-long-care-facilities/

                                 ______
                                 
               Statement Submitted by Eilon Caspi, Ph.D.
On June 13, 2019, the GAO released the report: Nursing Homes: Improved 
Oversight Needed to Better Protect Residents From Abuse. The GAO's 
investigation reported that CMS does not track ``abuse perpetrator 
type'' (such as staff or residents) in over 15,000 nursing homes 
nationwide. It urged CMS to bridge this major gap in oversight of 
nursing homes.

Two years prior to the GAO 2019 report, I published an extensive 
article in the Journal of Elder Abuse and Neglect identifying this gap 
including 20 reasons why it needs to be addressed by CMS.

Caspi, E. (2017). A federal survey deficiency citation is needed for 
resident-to-
resident aggression in U.S. nursing homes. Journal of Elder Abuse and 
Neglect, 29(4), 193-212.

In addition, the MDS 3.0, which is the largest federally-mandated 
clinical dataset in nursing homes also doesn't track resident-to-
resident incidents:

Caspi, E. (2013). M.D.S. 3.0--A giant step forward but what about items 
on 
resident-to-resident aggression? Journal of the American Medical 
Directors Association, 14(8), 624-625.

When this public health problem is not being tracked, for all practical 
purposes, it does not exist and CMS is not in a position to learn from 
these incidents to inform nationwide prevention. These injurious and 
deadly incidents remain invisible.

I've been focusing on the prevention of this prevalent and disturbing 
phenomenon of injurious and deadly neglect for over 13 years. For 
example, I published the first study in the U.S. on fatal resident-to-
resident incidents:

Caspi, E. (2018). The circumstances surrounding the death of 105 elders 
as a result of resident-to-resident incidents in dementia in long-term 
care homes. Journal of Elder Abuse and Neglect, 30(4), 284-308.

An early Harvard study showed that injurious resident-to-resident 
incidents are prevalent in U.S. nursing homes:

Shinoda-Tagawa et al. (2004). Resident-to-resident violent incidents in 
nursing homes. JAMA, 291(5), 591-598.

I've also co-directed the first documentary film on this phenomenon. 
The film is entitled Fighting for Dignity and it was produced by Terra 
Nova Films (released in early 2020).

My book, the first on the prevention of these incidents, will be 
published by Health Professions Press this summer.

Over the years, I've reviewed several hundred injurious and deadly 
resident-to-
resident incidents and came to learn that the vast majority of these 
incidents, especially in the context of resident with a serious brain 
disease such as Alzheimer's disease, are a form of neglect such as the 
neglect of meeting residents psychological and medical needs and 
neglect of supervision.

When I saw the GAO 2019 report and the aforementioned recommendation in 
it, I was hoping that CMS will finally require all 50 State Survey 
Agencies to track ``abuse perpetrator type'' (staff-to-resident abuse 
and resident-to-resident incidents).

However, nearly 20 months after the GAO report was released, CMS has 
yet to bridge this major gap in its oversight and enforcement 
activities of nursing homes. This, despite the fact that HHS concurred 
with the GAO recommendation.

Residents continue to be injured and die due to these resident-to-
resident incidents--even during the pandemic. It is important to point 
out that the majority of these incidents are preventable.

Would your committee consider urging CMS to implement the GAO 2019 
recommendation?

Specifically, this was GAO's ``priority'' recommendation:

``The administrator of CMS should require that abuse and perpetrator 
type be submitted by state survey agencies in CMS's databases for 
deficiency, complaint, and facility-reported incident data, and that 
CMS systematically assess trends in these data. (Recommendation 1).''

This was CMS response to the GAO recommendation:

``HHS concurred with this recommendation. In February 2020, HHS said 
CMS is developing the ability to review survey trends related to 
alleged perpetrator and alleged abuse types and aims to implement this 
recommendation by December 2020.''

The son of 87-year-old resident who had Alzheimer's disease and died 
four days after a resident with dementia pushed him and caused him to 
hit his head on the floor and sustain a blunt head trauma (determined 
in autopsy as the cause of death) said:

        ``We want to see a solution. We do not want the death of our 
        father to be in vain . . . We are out to find a solution. To 
        make sure that our aging population is taken care of. I want to 
        see something done so this doesn't happen again''

Thanks for your consideration,

Yours sincerely,

Eilon Caspi, Ph.D.
Gerontologist and Dementia Behavior Specialist
Assistant Research Professor
Institute for Collaboration on Health, Intervention, and Policy
University of Connecticut

Website: https://chip.uconn.edu

Adjunct Faculty
School of Nursing
University of Minnesota
Website: https://www.nursing.umn.edu

Founder and Director
Dementia Behavior Consulting LLC
Website: http://dementiabehaviorconsulting.com

Founding Member and Board Member
Elder Voice Family Advocates
Website: https://www.eldervoicefamilyadvocates.org

Board Member
Long-Term Care Community Coalition, NYC
https://nursinghome411.org

Editorial Board Member
Journal of Elder Abuse and Neglect

Author of the upcoming book: Understanding and Preventing Harmful 
Interactions Between Residents with Dementia. Health Professions Press. 
Scheduled release: Summer 2021.

Director of Documentary Film: ``Fighting for Dignity: Prevention of 
Harmful Interactions Between Residents with Dementia in Long-Term Care 
Homes.'' Terra Nova Films.
Webpage: https://tinyurl.com/td826r9

                                 ______
                                 
                        Center for Fiscal Equity

                      14448 Parkvale Road, Suite 6

                          Rockville, MD 20853

                      [email protected]

                    Statement of Michael G. Bindner

Chairman Wyden and Ranking Member Crapo, thank you for the opportunity 
to submit these comments for the record to the Subcommittee. I will not 
pull any punches.

This crisis is worse than you think. For whatever reason, the 
Coronavirus Task Force has ignored the first round of symptoms of this 
ailment. In my experience, it begins as a cold with heavy mucus. Bad 
timing made many sufferers believe that they had merely suffering from 
hay fever. There is then a week of dormancy. If you assume that 
exposure occurs 2 weeks prior to the first symptoms, there are four 
weeks, rather than two, before SARS symptoms are manifested, including 
fever, fatigue from low oxygen levels and fatigue from the manufacture 
of immunity (which feels like a gut punch over a 2-week period).

Ignoring the early symptoms in CDC guidelines means that, even with the 
best of care, the pandemic can blow through the nursing population 
before anyone realizes that COVID is running amok. The continuing 
denial of this model means that the disease will continue unabated 
until it runs out of vectors--meaning that vulnerable patients will 
continue to die until vaccinated.

On the positive side, our experience is that once one has marked 
symptoms, full immunity is most likely. Young people, who laughed off 
the early symptoms of the virus or simply did not experience it, are 
now getting sick. This could lead to another round of reinfection in 
nursing homes staffed with younger workers. Older workers, who likely 
have had symptoms, are now safer care givers for the elderly.

One of the developments no one talks about is the shedding of PPE. 
Healthcare workers see patients when they are after the contagious 
stage. Heavy PPE frightened people with the virus in the first wave had 
them avoid care until it was too late. Publicizing this will get people 
into care faster. Fearing death becomes a self-fulfilling prophecy when 
care given early will save lives.

Getting nursing home patients into a hospital setting will preserve 
their lives. Leaving their care to nursing home staff, especially when 
the disease is first evident, means that residents will get care from 
rookies. This is not a disease that tolerates mistakes in care.

COVID mortality has hastened death for older victims. Those who would 
have died of a heart attack within the next five years likely died this 
past year. We will see how high COVID deaths reach in comparison to 
heart attack death for the year. I suspect the latter will be down and 
the former may be second to cancer, if not the number one cause of 
death this year.

In comments provided to congressional committees last summer, I 
predicted at least 120 deaths per 100,000 individuals in the 
population. I had assumed that the nation would have done better than 
New York, which at the time had 150 deaths per 100,000. If mortality 
mirrors New York from that period, 500,000 people would have died. We 
have exceeded the more pessimistic estimate by tens of thousands.

Careful chart review will likely show under-reporting, so true death 
rates may turn out to approach 1,000,000 deaths. Let this sink in for a 
moment.

This virus originally did not hurt younger people. The latest variant 
is now making them very ill, but is less likely to kill them. By the 
time vaccines are available to them, they will have already been ill.

The science is now showing that children have more robust immune 
systems. To them, COVID-19 is just another cold virus to fight off. 
Their immune systems are in high gear. For this reason, vaccinating 
them will be a mistake. They need to build their immune systems by 
getting sick and recovering. Robbing them of this experience leaves 
them vulnerable to the next pandemic. They need to play in the dirt and 
with each other, even when sick. Colds are not Ebola. Treating it as 
such is counter-survival for the species.

Why were older people more vulnerable at first? Older citizens are 
farther away from having colds and being exposed to them. Current 
precautions also degrade immunity because it is not challenged. This is 
also why Influenza is so dangerous to nursing home residents. Older 
citizens who are not in a nursing home, especially those in a multi-
generational household, are less likely to become sick, primarily 
because their immune systems are challenged by their snot-nosed 
grandchildren.

Any parent will confirm that their younger children are constantly sick 
and that they share the pain--much to the horror of co-workers--
although having sick parents come to work also spreads manageable 
illness. Being shielded, however, leaves one vulnerable to symptoms. My 
daughter is with her mother in Knoxville. I got sick. My ex-wife 
probably will not, especially as she has just had her second shot.

A major problem in getting care is our insurance system. A single-payer 
system, either through a public option, Medicare for All or cooperative 
care through employee-owned and provided medicine, including nursing 
homes, will save lives in the next pandemic.

The attachment presented in 2019 is still as timely as it was then. 
Even more so, since it covers the public option within the Affordable 
Care and American Recovery Acts. If pre-existing conditions were 
repealed, for profit insurance would move more people to the public 
option each year, which would be their undoing. Single-payer health 
care as part of a bailout of the industry would be the natural result.

A recent paper by the National Bureau of Economic Research asking 
``Does Private Equity Investment in Healthcare Benefit Patients? 
Evidence from Nursing Homes'' is essential in addressing this issue. I 
commend it to your attention. You can find it online at https://
www.nber.org/papers/w28474.

Thank you for the opportunity to address the committee. We are, of 
course, available for direct testimony or to answer questions by 
members and staff.

Attachment--Single-Payer, June 12, 2019

There is no logic in rewarding people with good genes and punishing 
those who were not so lucky (which, I suspect, is most of us). Nor is 
there logic in giving health insurance companies a subsidy in finding 
the healthy and denying coverage for the sick, except the logic of the 
bottom line. Another term for this is piracy. Insurance companies, on 
their own, resist community rating and voters resist mandates--
especially the young and the lucky. As recent reforms are inadequate 
(aside from the fact of higher deductibles and the exclusion of 
undocumented workers), some form of single-payer is inevitable. There 
are three methods to get to single-payer.

The first to set up a public option and end protections for pre-
existing conditions and mandates. The public option would then cover 
all families who are rejected for either pre-existing conditions or the 
inability to pay. In essence, this is an expansion of Medicaid to 
everyone with a pre-existing condition. As such, it would be funded 
through increased taxation, which will be addressed below. A variation 
is the expansion of the Uniformed Public Health Service to treat such 
individuals and their families.

The public option is inherently unstable over the long term. The profit 
motive will ultimately make the exclusion pool grow until private 
insurance would no longer be justified, leading again to Single Payer 
if the race to cut customers leads to no one left in private insurance 
who is actually sick. This eventually becomes Medicare for All, but 
with easier passage and sudden adoption as private health plans are 
either banned or become bankrupt. Single-payer would then be what 
occurs when

The second option is Medicare for All, which I described in an 
attachment to yesterday's testimony and previously in hearings held May 
8, 2019 (Finance) and May 8, 2018 (Ways and Means). Medicare for All is 
essentially Medicaid for All without the smell of welfare and with 
providers reimbursed at Medicare levels, with the difference funded by 
tax revenue.

Medicare for All is a really good slogan, at least to mobilize the 
base. One would think it would attract the support of even the Tea 
Partiers who held up signs saying ``Don't let the government touch my 
Medicare!'' Alas, it has not. This has been a conversation on the left 
and it has not gotten beyond shouting slogans either. We need to decide 
what we want and whether it really is Medicare for All. If we want to 
go to any doctor we wish, pay nothing and have no premiums, then that 
is not Medicare.

There are essentially two Medicare's, a high option and a low one. One 
option has Part A at no cost (funded by the Hospital Insurance Payroll 
Tax and part of Obamacare's high unearned income tax as well as the 
general fund), Medicare Part B, with a 20% copay and a $135 per month 
premium and Medicare Part D, which has both premiums and copays and is 
run through private providers. Parts A and B also are contracted out to 
insurance companies for case management. Much of this is now managed 
care, as is Medicare Advantage (Part C).

Obamacare has premiums with income-based supports and copays. It may 
have a high option, like the Federal Employee Health Benefits Program 
(which also covers Congress) on which it is modeled, a standard option 
that puts you into an HMO. The HMO drug copays for Obamacare are higher 
than for Medicare Part C, but the office visit prices are exactly the 
same.

What does it mean, then, to want Medicare for All? If it means we want 
everyone who can afford it to get Medicare Advantage Coverage, we 
already have that. It is Obamacare. The reality is that Senator Sanders 
wants to reduce Medicare copays and premiums to Medicaid levels and 
then slowly reduce eligibility levels until everyone is covered. Of 
course, this will still likely give us HMO coverage for everyone except 
the very rich, unless he adds a high-option PPO or reimbursable plan.

Either Medicare for All or a real single payer would require a very 
large payroll tax (and would eliminate the HI tax) or an employer paid 
subtraction value added tax (so it would not appear on receipts nor 
would it be zero rated at the border, since there would be no evading 
it), which we discuss below, because the Health Care Reform debate is 
ultimately a tax reform debate. Too much money is at stake for it to be 
otherwise, although we may do just as well to call Obamacare Medicare 
for All.

The third option is an exclusion for employers, especially employee-
owned and cooperative firms, who provide medical care directly to their 
employees without third party insurance, with the employer making HMO-
like arrangements with local hospitals and medical practices for 
inpatient and specialist care.

Employer-based taxes, such as a subtraction VAT or payroll tax, will 
provide an incentive to avoid these taxes by providing such care. 
Employers who fund catastrophic care or operate nursing care facilities 
would get an even higher benefit, with the proviso that any care so 
provided be superior to the care available through Medicaid or Medicare 
for All. Making employers responsible for most costs and for all cost 
savings allows them to use some market power to get lower rates.

This proposal is probably the most promising way to arrest health care 
costs from their current upward spiral--as employers who would be 
financially responsible for this care through taxes would have a real 
incentive to limit spending in a way that individual taxpayers simply 
do not have the means or incentive to exercise. The employee-ownership 
must ultimately expand to most of the economy as an alternative to 
capitalism, which is also unstable as income concentration becomes 
obvious to all.

The key to any single-payer option is securing a funding stream. While 
payroll taxes are the standard suggestion, there are problems with 
progressivity if such taxes are capped and because profit remains 
untaxed, which requires the difference be subsidized through higher 
income taxes. For this reason, funding should come through some form of 
value-added tax.

Timelines are also concerns. Medicare for All be done gradually by 
expanding the pool of beneficiaries, regardless of condition. Relying 
on a Public Option will first serve the poorest and the sickest, but 
with the expectation that private insurance will enlarge the pool of 
those not covered until the remainder can safely be incorporated into a 
single-payer system through legislation or bankruptcy.

                                 ______
                                 
                      Center for Medicare Advocacy

                 1025 Connecticut Avenue, NW, Suite 709

                          Washington, DC 20036

                             (202) 293-5760

          Statement of Toby S. Edelman, Senior Policy Attorney

The Center for Medicare Advocacy is a national non-profit law 
organization founded in 1986. The Center provides legal assistance, 
education, analysis, and advocacy to advance access to comprehensive 
Medicare coverage and high quality care for older people and people 
with disabilities. The Center focuses on the concerns of people with 
chronic conditions and those in need of long-term care. The 
organization's positions and actions are based on the experiences of 
the people we hear from every day.

Thank you for holding this important hearing on COVID-19 in the 
nation's nursing homes. The experience of COVID-19 is indeed a national 
tragedy. Although the early days of the coronavirus pandemic were 
especially chaotic, when little was known about asymptomatic spread of 
the virus, there is no question that better staffing and infection 
control practices could have prevented, and, in some facilities, did 
prevent, many cases and deaths among residents and staff.\1\
---------------------------------------------------------------------------
    \1\ Cinnamon St. John, ``Geography Is Not Destiny: Protecting 
Nursing Home Residents from the Next Pandemic'' (Feb. 2021), https://
medicareadvocacy.org/wp-content/uploads/2021/02/CMA-NH-Report-
Geography-is-Not-Destiny.pdf.

The coronavirus pandemic has exacerbated longstanding problems in the 
nation's nursing homes and brought them all too vividly to national 
attention. These problems must be corrected to ensure that the next 
public health crisis does not result, again, in such devastation, 
overwhelming loss of life, and serious harm to residents' health and 
quality of life.\2\
---------------------------------------------------------------------------
    \2\ Michael Levere, Patricia Rowan, Andrea Wysocki, ``The adverse 
events of the COVID-19 pandemic on nursing home resident well-being,'' 
Journal of the American Medical Directors Association (Journal Pre-
proof published Mar. 2021), https://www.jamda.com/article/S1525-
8610(21)00306-6/pdf (documenting negative consequences of pandemic on 
Connecticut nursing home residents, including increases in depression, 
unplanned weight loss, and incontinence and deterioration in cognitive 
function, resulting from residents' loneliness and isolation).
---------------------------------------------------------------------------

Longstanding Problems

    1.  Inadequate nurse staffing levels, both professional and 
paraprofessional

The lack of sufficient numbers of nursing staff has been known for 
decades. In 2000, a federal study mandated by the 1987 Nursing Home 
Reform Law documented that more than 90 percent of nursing facilities 
did not have sufficient staff to prevent avoidable harm or to meet 
standards of care set out in the Reform Law.\3\ Staffing levels have 
not changed in the two decades since the report was issued, despite the 
increased frailty and acuity of the resident population.
---------------------------------------------------------------------------
    \3\ CMS, Report to Congress: Appropriateness of Minimum Nurse 
Staffing Ratios (2001).

The coronavirus pandemic has continued to highlight the dire 
consequences of inadequately staffing nursing facilities. Study after 
study documents that facilities without sufficient nursing staff have 
both more cases of COVID-19 and more deaths from the virus.\4\ A study 
of nursing facilities in Connecticut found that 20 minutes of 
additional registered nurse care per resident per day was correlated 
with 22% fewer COVID-19 cases among residents and 26% fewer deaths.\5\
---------------------------------------------------------------------------
    \4\ CMA Alert, ``Studies Find Higher Nurse Staffing Levels in 
Nursing Facilities Are Correlated With Better Containment of COVID-19'' 
(Aug. 13, 2020), https://medicareadvocacy.org/studies-find-higher-
nurse-staffing-levels-in-nursing-facilities-are-correlated-with-better-
containment-of-covid-19/ (citing multiple studies). See also Jose F. 
Figueroa, Rishi K. Wadhera, Irene Papanicolas, et al, ``Association of 
Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse 
Staffing With COVID-19 Cases,'' JAMA Network (Aug. 10, 2020), https://
jamanetwork.com/journals/jama/fullarticle/
2769437?guestAccessKey=258f9d19-b7c2-43e2-9218
-
55c23d3914bc&utm_source=silverchair&utm_medium=email&utm_campaign=articl
e_alert-jama
&utm_content=olf&utm_term=081020.
    \5\ Yue Li, H. Temkin-Greener, S. Gao, X. Cai, ``COVID-19 
infections and deaths among Connecticut nursing home residents: 
facility correlates,'' Journal of American Geriatrics Society (2020), 
https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16689.

In January 2021, the New York State Attorney General found ``Staffing 
was more determinative of death rates than `COVID-19 geography' during 
the initial wave of the pandemic.''\6\ Attorney General James found 
that although the harshest impact of COVID-19 was in New York City and 
neighboring counties at the beginning of the pandemic, the death rate 
was half in facilities in this geographic area that had the highest (5-
star) ratings in staffing.
---------------------------------------------------------------------------
    \6\ New York State Office of the Attorney General Letitia James, 
Nursing Home Response to COVID-19 Pandemic, p. 30 (revised Jan. 30, 
2021), https://ag.ny.gov/sites/default/files/2021-
nursinghomesreport.pdf.

The direct care workforce also needs to be strengthened. The 
paraprofessional workers who provide most of the hands-on care for 
residents need a living wage \7\ and comprehensive benefits, including 
paid sick leave.\8\ Over the past year, the virus has been spread to 
residents and staff by infected but asymptomatic workers who work in 
multiple facilities, often because they earn such low wages, minimum 
wage or just above minimum wage, that they need multiple jobs to try to 
make ends meet and pay their bills. Direct care workers frequently lack 
health insurance and paid sick leave, leading them to work when 
sick.\9\
---------------------------------------------------------------------------
    \7\ LeadingAge recently released a report finding that paying a 
living wage to the direct care workforce could pay for itself, just by 
improving care for residents. Making Care Work Pay: How Paying at Least 
a Living Wage to Direct Care Workers Could Benefit Care Recipients, 
Workers, and Communities, https://leadingage.org/sites/default/files/
Making%20Care%20Work%20Pay
%20Report.pdf?_ga=2.118488393.1154178586.1601481977-
1021098696.1598989890.
    \8\ PHI, Caring for the Future: The Power and Potential of 
America's Direct Care Workforce (Jan. 12, 2021), reached through a link 
at Caring for the Future: The Power and Potential of America's Direct 
Care Workforce--PHI (phinational.org).
    \9\ Harold Van Houtven, Nicole DePasquale, Norma B. Coe, 
``Essential Long-Term Care Workers Commonly Hold Second Jobs and 
Double- or Triple-Duty Caregiving Roles,'' Journal of the American 
Geriatrics Society, Vol. 68, Issue 8, pp. 1657-1660 (published Apr. 27, 
2020), https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/
jgs.16509.
---------------------------------------------------------------------------
    2.  Poor infection control practices

In May 2020, the Government Accountability Office (GAO) reported that 
infection control was the most frequently cited deficiency in nursing 
homes in the pre-
pandemic period 2013-2017, with 40 percent of facilities cited each 
year and 82 percent cited at least once in the 5-year period.\10\ The 
guidance for COVID-19 is no different from the guidance for all 
infections: staff must wash their hands, properly disinfect medical 
equipment between residents, properly and consistently use personal 
protective equipment, and identify, track, and isolate residents who 
appear to have, or who are confirmed to have, infectious diseases.
---------------------------------------------------------------------------
    \10\ ``Infection Control Deficiencies Were Widespread and 
Persistent in Nursing Homes Prior to COVID-19 Pandemic,'' GAO-20-576R, 
p. 4 (May 20, 2020), https://www.gao.gov/products/GAO-20-576R.

---------------------------------------------------------------------------
    3.  Limited enforcement of standards of care

The GAO reports that only one percent of facilities cited with an 
infection control deficiency between 2013 and 2017 received any kind of 
financial penalty.\11\ Facilities ignore deficiencies when they know 
deficiencies are unlikely to be cited and, if cited, unlikely to lead 
to any consequence.
---------------------------------------------------------------------------
    \11\ Id.

The Trump Administration dramatically rolled back the already-weak 
federal enforcement system, largely through sub-regulatory guidance 
documents (survey and certification letters addressed to state survey 
agencies).\12\ The result of the changes has been few and comparatively 
small per instance financial penalties (rather than per day penalties 
that the Obama Administration mandated as the default type of civil 
money penalty). The few reported decisions by Administrative Law Judges 
that have been issued since the Trump Administration decimated the 
enforcement system suggest that no financial penalties were imposed for 
facilities' noncompliance or that penalties were so low that facilities 
chose not to appeal or both.
---------------------------------------------------------------------------
    \12\ See Jordan Rau, ``Trump Administration Eases Nursing Home 
Fines in Victory for Industry,'' The New York Times (Dec. 24, 2017), 
https://www.nytimes.com/2017/12/24/business/trump-administration-
nursing-home-penalties.html?searchResultPosition=2; Toby S. Edelman, 
``Deregulating Nursing Homes,'' Bifocal, Vol. 39, No. 3, p. 31 (Jan.-
Feb. 2018), final-bifocal_39_3.pdf (americanbar.org); testimony of Toby 
S. Edelman at Hearing before House Ways and Means Committee, 
Subcommittee on Health, ``Examining the COVID-19 Nursing Home Crisis 
(Jun. 25, 2020), https://waysandmeans.house.gov/sites/
democrats.waysandmeans.house.
gov/files/documents/Toby%20Edelman_Testimony.pdf.
---------------------------------------------------------------------------

Solutions

    1.  Require meaningful nurse staffing levels and reverse the 
dismantling of the enforcement system

The Senate Finance Committee must require meaningful nurse staffing 
ratios at all levels and require improved salaries, benefits, and 
working conditions for the paraprofessional workforce. The Committee 
further needs to call on the Centers for Medicare and Medicaid Services 
to reverse the dismantling of the enforcement system so that meaningful 
and appropriate sanctions are promptly imposed for noncompliance with 
federal standards of care.

In addition, the Committee needs to address changes in the nursing home 
industry since the 1987 Nursing Home Reform Law was enacted that have 
reduced accountability for the quality of care that facilities provide 
and for public spending.

    2.  Enact laws to prohibit or at least restrict/reduce provider 
self-dealing

Jordan Rau of Kaiser Health News reported in The New York Times 3 years 
ago that nearly three-quarters of all nursing facilities in the country 
buy goods and services, such as therapy services, management services, 
medications, and rent, often at inflated prices, from companies that 
they own and control.\13\ The result of these related-party 
transactions is that facilities are able to hide profits as the cost of 
doing business. In 2015, facilities' contracts with related parties 
accounted for $11 billion, a tenth of facilities' Medicare 
reimbursement. Rau described two New York owners whose family trusts 
took $40 million of the $145 million that their facilities received as 
reimbursement over an 8-year period--a 28 percent profit margin. Rau 
reported Kaiser Health News's analysis that found facilities engaging 
in these practices have fewer nurses and aides to provide care to 
residents, ``higher rates of patient injuries and unsafe practices,'' 
and twice as many complaints as other facilities.
---------------------------------------------------------------------------
    \13\ Jordan Rau, ``Care Suffers as More Nursing Homes Feed Money 
Into Corporate Webs,'' The New York Times (Jan. 2, 2018), https://
www.nytimes.com/2018/01/02/business/nursing-homes-care-
corporate.html?searchResultPosition=9.

In December 2020, Debbie Cenziper and colleagues at The Washington Post 
documented the self-dealing of California's largest nursing home 
operator, Brius Healthcare Services, whose nursing facilities paid $103 
million to related companies in 2018 for supplies, administrative 
services and financial consulting, and rent, among other services.\14\ 
Care at many Brius facilities was so poor that, in 2014, then-
California Attorney General Kamala Harris took an unprecedented step of 
filing an emergency motion in bankruptcy court in an effort to prevent 
the court from giving Brius additional facilities. Harris's motion 
called the company a ``serial violator of rules within the skilled 
nursing industry.''
---------------------------------------------------------------------------
    \14\ Debbie Cenziper, ``Profit and pain: How California's largest 
nursing home chain amassed millions as scrutiny mounted,'' Washington 
Post (Dec. 31, 2020), https://www.washingtonpost.
com/business/2020/12/31/brius-nursing-home.

The Naples Daily News reported in 2018 that Consulate Health Care, the 
largest nursing home operator in Florida and sixth largest operator in 
the country (with 210 facilities and 22,059 beds in 21 states), founded 
in 2006 and owned by the 
Atlanta-based private equity firm Formation Capital, designed its 
facilities ``to appear cash-strapped.''\15\ The article described the 
chain's individual facilities as ``essentially empty shells, they pay 
rent, management and rehabilitation service fees to Consulate or 
Formation Capital-affiliated companies.'' One Consulate facility paid 
$467,022 in management fees and $294,564 in rent to two companies owned 
by Consulate and Formation Capital. Forty-eight of Consulate's 77 
Florida nursing facilities had one or two stars, the lowest ratings, on 
the federal website, then called Nursing Home Compare. In ``an 
unprecedented action'' in January 2018, the state threatened to close 
53 of the corporation's 77 Florida facilities under a state law that 
authorizes revocation of state licenses for serious violations at 
facilities under common ownership.\16\
---------------------------------------------------------------------------
    \15\ Ryan Mills and Melanie Payne, ``Neglected: Florida's largest 
nursing home owner represents trend toward corporate control,'' Naples 
Daily News (May 31, 2018), https://www.
naplesnews.com/story/news/special-reports/2018/05/31/floridas-largest-
nursing-home-owner-part-growing-national-trend/581511002/.
    \16\ Ryan Mills and Melanie Payne, ``Neglected: Florida's largest 
nursing home chain survives despite legacy of poor patient care,'' 
Naples Daily News (May 31, 2018), https://www.
naplesnews.com/story/news/special-reports/2018/05/31/neglected-fraud-
and-abuse-nursing-homes-florida/542609002/.

    3.  Enact laws (with enforceable consequences for violations) 
limiting the amount of public reimbursement that can be spent on 
---------------------------------------------------------------------------
profits, administration, and overhead

A financial issue related to self-dealing is the need for new federal 
and state rules to require facilities to spend designated portions of 
their reimbursement on care of residents and to set, and enforce, 
strict limits on how much can be spent on administrative costs, 
management fees, and profits. Congress enacted such rules, called 
medical loss ratios, in the Affordable Care Act for Medicare managed 
care plans. The state of New Jersey recently enacted legislation for 
nursing facilities to mandate direct care ratios, which limit the 
percentage of reimbursement that can be spent on administrative costs 
and profits.\17\
---------------------------------------------------------------------------
    \17\ A4482/S2758, https://www.njleg.state.nj.us/2020/Bills/A4500/
4482_R2.PDF; ``Governor Murphy Signs Legislative Package to Strengthen 
the Resiliency and Preparedness of New Jersey's Long-Term Care 
Industry'' (News Release, Sep. 16, 2020), https://www.nj.gov/governor/
news/news/562020/approved/20200916b.shtml.

Congress should enact direct care ratio requirements for the Medicare 
---------------------------------------------------------------------------
and Medicaid reimbursement that facilities receive.

    4.  Enact laws (with enforceable consequences for violations) 
identifying who is eligible to own and manage nursing facilities

Nursing facilities are bought and sold and management contracts are 
signed with virtually no oversight and few limits set by states. 
Increasingly, multiple limited liability companies take pieces of a 
nursing home business. With multiple companies, it is difficult, and 
intentionally so,\18\ for government and private parties to hold 
facilities accountable for poor care.
---------------------------------------------------------------------------
    \18\ Joseph E. Casson and Julia McMillen, ``Protecting Nursing Home 
Companies: Limiting Liability Through Corporate Restructuring,'' 
Journal of Health Law, Fall 2003, Vol. 36, No. 4.

Secrecy surrounds changes of ownership and management. The example of 
Skyline Healthcare is illustrative. Beginning in late 2015, the New 
Jersey-based Skyline Healthcare took over management of more than 100 
facilities across the country in little more than year. Almost as 
quickly as it acquired facilities, Skyline began to default, failing to 
pay vendors and staff. States across the country went to court to get 
receiverships in order to be able to pay vendors and staff and provide 
residents with food and medications.\19\ Information about new owners 
was often kept secret. On April 27, 2018, for example, Pennsylvania 
installed a temporary manager at nine facilities operated by Skyline, 
but the state declined to identify the manager.\20\ As reported on May 
5, Pennsylvania identified as the new operator of the Skyline facility 
in Lancaster a new for-profit company that had been created just three 
days earlier, on May 2. The so-called new operator was not actually 
new. It had at least two of the same owners and shared the address of a 
company, Priority Healthcare Group, that had actually bought 14 
facilities in the state in 2016.\21\ Priority's record managing 11 
former Golden Living facilities in Pennsylvania was poor. Priority cut 
staffing levels and reduced other spending at the facilities.\22\ Yet 
this is the so-called new company that Pennsylvania entrusted with a 
former Skyline facility.
---------------------------------------------------------------------------
    \19\ Laura Strickler, Stephanie Gosk, Shelby Hanssen, ``A nursing 
home chain grows too fast and collapses, and elderly and disabled 
residents pay the price,'' NBC News (Jul. 19, 2019), https://
www.nbcnews.com/health/aging/nursing-home-chain-grows-too-fast-
collapses-elderly-disabled-residents-n1025381.
    \20\ Harold Brubaker, ``Pa. ousts Skyline Healthcare from nine Pa. 
nursing homes,'' Philadelphia Inquirer (May 2, 2018), Pa. ousts Skyline 
Healthcare from nine Pa. nursing homes (inquirer.com).
    \21\ Heather Stauffer, ``Lancaster nursing home formerly run by 
Skyline has a new operator,'' Lancasteronline (May 26, 2018), https://
lancasteronline.com/news/local/lancaster-nursing-home-formerly-run-by-
skyline-has-a-new/article_7df1ad0a-6057-11e8-937b-3393e543dbb7.html.
    \22\ Daniel Simmons-Ritchie, ``Worst nursing homes continue to fail 
the frail despite lawsuit and promises; Golden Living's homes changed 
hands, but the care never got better,'' PennLive (Nov. 26, 2018), 
https://www.witf.org/2018/11/26/worst-nursing-homes-continue-to-fail-
the-frail-despite-lawsuit-and-promises/.

State licensure rules governing ownership and management are openly 
flouted. For example, New York purchasers of five nursing facilities in 
Vermont began operating the facilities in October 2020,\23\ before 
going through a new state review process for nursing home sales that 
requires consideration of past records at other facilities.\24\ The New 
Yorkers' record includes Priority Healthcare Group, whose Pennsylvania 
facilities were cited with low staffing levels and poor quality 
care.\25\
---------------------------------------------------------------------------
    \23\ Katie Jickling, ``Three New York-based owners take over 
management of five Genesis nursing homes,'' Vtdigger (Nov. 13, 2020), 
https://vtdigger.org/2020/11/13/three-new-york-based-owners-takes-over-
management-of-five-genesis-nursing-homes/.
    \24\ Bill No. 125, 2018, establishing Nursing Home Oversight 
Working Group and (section 3) an Interim Review Process for Transfer of 
Nursing Home Ownership (effective July 1, 2018), https://
legislature.vermont.gov/Documents/2018/Docs/ACTS/ACT125/
ACT125%20As%20En
acted.pdf; signed by Governor May 10, 2018, hj180510.pdf (vermont.gov).
    \25\ Daniel Simmons-Ritchie, ``Worst nursing homes continue to fail 
the frail despite lawsuit and promises; Golden Living's homes changed 
hands, but the care never got better,'' PennLive (Nov. 26, 2018), 
https://www.witf.org/2018/11/26/worst-nursing-homes-continue-to-fail-
the-frail-despite-lawsuit-and-promises/.

The federal government appears to believe that any facility with a 
state license is eligible for Medicare and Medicaid certification, no 
questions asked. The abandonment of state or federal responsibility and 
actions to ensure that only qualified owners and managers own and 
operate nursing facilities has led to the growing concentration of 
nursing facilities in private equity firms, real estate investment 
trusts, and other private owners that have little apparent knowledge 
about or interest in providing high quality care, to the detriment of 
residents and staff. This issue is not new but has only gotten worse 
---------------------------------------------------------------------------
over time.

More than 25 years ago, in 1994, Jon Robertson formed Phoenix Health 
Group and acquired nursing facilities in California. The Los Angeles 
Times reported in 1997, ``As the money began to roll in from Medicare 
and Medi-Cal payments to the more than 300 residents at the facilities, 
Robertson, who had long displayed a fondness for life's pricier 
pleasures--from Harley-Davidson motorcycles to diamond rings--began to 
spend conspicuously.''\26\ In 1996, Robertson checked into a 
rehabilitation center in Phoenix to deal with a cocaine addiction. 
Robertson also ``served prison time and owed $150,000 in restitution to 
the IRS for filing a false tax return as president of another nursing 
home management company.''\27\ Robertson's California facilities 
provided poor care for residents and were cited with numerous 
deficiencies. The company filed for bankruptcy and abruptly closed its 
facilities.
---------------------------------------------------------------------------
    \26\ Eric Slater, ``Entrepreneur Fades From View as Empire 
Collapses,'' Los Angeles Times (Oct. 23, 1997), https://
www.latimes.com/archives/la-xpm-1997-oct-23-mn-45876-story.html.
    \27\ The Associated Press, ``Utah company facing bankruptcy; 
nursing home residents in limbo,'' The Salt Lake Tribune (May 13, 
2015).

Despite this record and sometime after his drug rehabilitation and 
prison sentence, Robertson formed a new company, Utah-based Deseret 
Health Group. Multiple states gave licenses to facilities owned by 
Robertson's new company and the federal government certified the 
facilities for Medicare and Medicaid reimbursement. In early May 2015, 
Robertson repeated his pattern from California. Deseret abruptly 
stopped paying for food, medical supplies, and workers' wages and 
benefits in nursing facilities owned by the company in Kansas, 
Minnesota, Nebraska, and Wyoming. States pursued court receiverships or 
otherwise took control of the facilities to protect residents and 
ensure they received food and medications.\28\
---------------------------------------------------------------------------
    \28\ See, e.g., H.B. Lawson, ``Nursing home faces closure,'' The 
Saratoga Sun (May 6, 2015), https://www.saratogasun.com/story/2015/05/
06/news/nursing-home-faces-closure/3898.html.

Private equity ownership of nursing homes has created special problems. 
In 2007, The New York Times reported ``more profit and less nursing'' 
in facilities owned by private equity firms.\29\
---------------------------------------------------------------------------
    \29\ Charles Duhigg, ``At Many Nursing Homes, More Profit and Less 
Nursing,'' The New York Times (Sep. 23, 2007), https://www.nytimes.com/
2007/09/23/business/23nursing.html.

A research study looking at nursing home ownership between 2000 and 
2017 found that private equity (PE) ownership increased the probability 
of death during a resident's stay by 1.7 percentage points (meaning 
that ``about 20,150 Medicare lives [were] lost due to PE ownership'') 
while Medicare costs for residents' care increased by 11 percent.\30\ 
Facilities owned by private equity firms reduced staffing and 
increased, by 50 percent, the use of antipsychotic drugs.
---------------------------------------------------------------------------
    \30\ Atul Gupta, Sabrina T. Howell, Constantine Yannelis, and 
Abhinav Gupta, ``Does Private Equity Investment in Healthcare Benefit 
Patients? Evidence from Nursing Homes,'' Becker Friedman Institute, 
Working Paper No. 2021-20 (Feb. 2021), https://bfi.uchicago.edu/wp-
content/uploads/2021/02/BFI_WP_2021-20.pdf.

During the coronavirus pandemic, The Washington Post reported that 
Portopiccolo Group, a private equity firm with a record of poor care 
(nearly 70 percent of Portopiccolo facilities have ratings of one or 
two (of five) on the federal website), short staffing, and coronavirus 
outbreaks, bought at least 22 nursing facilities, with ``scant 
scrutiny'' from state regulators in Maryland and Virginia.\31\ As in 
the facilities it already owned, Portopiccolo reduced operating 
expenses (reducing cleaning supplies and personal protective equipment) 
and reduced workers' benefits. The results were poorer care for 
residents.
---------------------------------------------------------------------------
    \31\ Rebecca Tan and Rachel Chason, ``An investment firm snapped up 
nursing homes during the pandemic. Employees say care suffered,'' The 
Washington Post (Dec. 21, 2020), https://www.washingtonpost.com/local/
portopiccolo-nursing-homes-maryland/2020/12/21/a1ffb2a6-292b-11eb-9b14-
ad872157ebc9_story.html.

A February 2021 posting in Health Affairs made these points in a 
---------------------------------------------------------------------------
scathing indictment of the nursing home industry:

        Prior to the pandemic, persistent problems with nursing home 
        care had been documented for years, often because of too few 
        and inadequately trained frontline staff. The harm to frail 
        older adults can be quite severe--abuse and sexual assault, 
        infections, overuse of psychotropic medications, pressure 
        ulcers, falls with injuries, weight loss, dehydration, pain, 
        and medication errors. Infection control violations have also 
        been found repeatedly in a majority of nursing homes.

        Quality issues persist as policy makers are unable to oversee 
        how nursing homes spend Medicare and Medicaid payments. The 
        growth in complex nursing-home ownership structures has limited 
        financial transparency by allowing nursing homes to hide public 
        payments and stint on direct resident care. We recommend 
        specific policy changes to make ownership, management, and 
        financing more transparent and accountable to improve U.S. 
        nursing home care.\32\
---------------------------------------------------------------------------
    \32\ Charlene Harrington, Anne Montgomery, Terris King, David C. 
Grabowski, Michael Wasserman, ``These Administrative Actions Would 
Improve Nursing Home Ownership and Financial Transparency in the Post 
COVID-19 Period,'' Health Affairs (Feb. 11, 2021), https://
www.healthaffairs.org/do/10.1377/hblog20210208.597573/full/.

The Committee should address the issue of nursing home ownership and 
management and enact, with appropriate enforcement mechanisms, 
meaningful statutory standards for state licensure and federal 
certification.

Conclusion

Staffing is the critical factor that makes good care possible. Unless 
facilities have sufficient professional and paraprofessional staff and 
treat all staff well, care will not improve. Improving staffing is 
absolutely necessary, but it is not sufficient.

In addition, states and the federal government need to limit licensure 
and certification, respectively, to owners and managers that are 
knowledgeable about and demonstrate commitment and the financial 
capacity to provide high quality care to residents. Finally, public 
reimbursement must be spent on care for residents and not diverted to 
management fees, overhead, and excessive profits.

Many of these issues have been raised before.\33\ The Committee now has 
the opportunity to dramatically improve care for residents and working 
conditions for workers by addressing these issues.
---------------------------------------------------------------------------
    \33\ ``Buying and Selling Nursing Homes: Who's Looking Out for the 
Residents?'' (CMA Alert, May 23, 2018), https://medicareadvocacy.org/
buying-and-selling-nursing-homes-whos-looking-out-for-the-residents/.

                                 ______
                                 
               Statement Submitted by Elizabeth Hamilton
Thank you, Chairman Wyden, Ranking Member Crapo, and members of the 
Senate Finance Committee, for allowing additional statements to this 
hearing. My name is Elizabeth Hamilton. My mother is 96 years old and 
currently is a resident in a memory care unit in Seattle, Washington.

On March 10, 2021 The Center for Medicaid and Medicare Services (CMS) 
released updated and expanded guidelines for inside and in person 
visitation in Nursing Homes. Unfortunately the facility my mother is in 
has not updated their restrictions to comply with these new guidelines 
stating they are following state guidelines. The Governor as of this 
writing has not released any changes to the current restrictions now in 
place.

Residents of long-term care (LTC) have been languishing in facilities 
across the nation, in varying degrees of ``lockdown'' since March 13, 
2020. Initially, scores succumbed to a deadly virus we knew little 
about. Facilities were not prepared; none of us were. Much has changed 
in a year. It's time for CMS to reinforce adherence to existing 
guidelines for compassionate care visits, essential caregiver 
designation, and infection control, and to update its guidance for the 
safe and strategic reopening of facilities.

LTC facilities now have the capacity to follow proven protocols--
masking, social distancing, disinfection, selectively restricted 
movement. Testing is widely available. Infection and death rates in 
long-term care have dropped dramatically. Many staff, residents and 
family members have been (or soon will be) injected and protected with 
incredibly effective vaccines, far more than they typically are from 
seasonal flu. A year ago we talked about ``protecting the most 
vulnerable.'' With proven safety precautions in place, testing 
available, and vaccinations given, a year later we are ``protecting 
them to death.'' At the same time, guidelines allowing for 
compassionate care visits and essential caregiver designation are being 
completely ignored by many facilities, and proper infection control is 
not happening everywhere. You can help eliminate these disparities.

Families have been patient, hunkering down outdoors, even in frigid 
temperatures, to connect with their loved ones. LTC residents are 
depressed and despondent, as are staff members. Our loved ones are 
suffering from increased falls and troubling weight loss. Many have 
gone nearly a year without a haircut or a thorough teeth cleaning. Some 
have given up and died quietly, either with no family present or with 
the requisite one or two family members at their bedsides. The negative 
physical and emotional toll of these policies on our families far 
outweighs any benefit.

Some facilities in the nation have begun to open up. But with 
guidelines from last fall still in place, regardless of vaccine status 
among residents, an entire facility is still on lockdown for a singular 
asymptomatic case. This makes no sense. The injury to our loved ones 
and our families goes on and on.

We need swift delivery of updated, common sense guidelines to safely 
and strategically open up facilities, balancing vastly decreased risk 
from the virus with quality of life. You have the ability to end the 
isolation that has devastated lives in long-term care and reunite our 
families. We have all suffered long enough. It is time.

                                 ______
                                 
                  Statement Submitted by Tamra Holland
Members of the Senate Finance Committee, thank you for choosing to make 
the tragedies that occurred residential facilities throughout the 
United States over the past 13 months a focus of your attention. I 
write to you as one of thousands of family members painfully familiar 
with an aspect of this story not well understood by the majority of 
Americans.

My mother Darlene entered a facility on March 18, 2020 for 
rehabilitation following a stroke the month before. She had made good 
physical progress in an acute hospital rehabilitation but needed 
additional time of daily professional therapies. During the hospital 
rehabilitation prior the lockdown, family was present with her every 
day for therapy homework, helping with her personal care and emotional 
well-being. We knew once transferred to the long-term care rehab 
facility we would not be able to immediately visit but had faith her 
care needs would be meet and we would be involved in some manner.

My mother-in-law Joan was also a long-term resident of this facility in 
the skilled nursing wing. My husband and I visited her regularly and 
were comfortable with her care.

Having many family members on the front lines of healthcare and a long 
career in pharmacy myself, I understood the need for a lockdown in 
March of 2020. The pandemic was a roaring freight train and even the 
best of facilities needed that sudden stop in visitation. There was not 
enough known about the virus, there was not enough PPE, residential 
facilities did not have the infection control policies that the 
pandemic required. They were not prepared, none of us were.

Having to say goodbye to my Mother as the facility van picked her up at 
the hospital was heartbreaking. However, at that point I still expected 
the facility care would be appropriate and she would get the 
rehabilitation therapy she needed to return to independently living in 
her apartment. What I found was a facility that suddenly had an 
overwhelmed phone system and no communication plan for families. I 
could see through my Mom's window that she was still in bed at noon 
each day. None of her personal belongings were unpacked or put away. 
She experienced a fall within the first 48 hours of being in the 
facility. Mom was confused with the change in environment and no one 
there to help her acclimate. The staff were used to family helping 
settle in new residents and personalizing the sterile environment of 
the room. Staff did not seem aware there was a gap in care because 
family was not inside the building.

In these early days I expected communication was key to Mom's quality 
of care and rehabilitation as well as the continued good care of my 
Mother-in-law Joan. Phone contact was difficult because you could not 
call directly to the nursing unit to speak to staff. A central operator 
had difficulty suddenly fielding all communication coming in. Calls 
then transferred to the nursing unit frequently were never answered. 
Imagine the anxiety of trying to speak to staff about a loved one's 
care and listening to the phone ring and ring. This lack of contact, 
the lack of any direct information lead to an assumption of lack of 
care. When your mind does not have valid information to deal with it 
imagines something that can be vastly different than the reality. This 
was the situation for months as no visiting was allowed. I tried email 
with the facility director which went unanswered. I left voicemails and 
phone messages. I left things at the front door for both Darlene and 
Joan hoping they would know that we still cared about them. Darlene had 
a cellphone and we sometimes were able to speak to her. However, often 
the phone was not answered because she could not hear it, could not 
find it or it wasn't charged. Asking staff to help her with the phone 
required the same phone contact that I described above. Joan was not 
able to hold a phone and requesting staff help her was often met with 
exasperation. I established contact with the facility corporate 
leadership. At first this seemed it would be productive. I asked for 
some avenues of communication, establishment of a family council, 
family newsletter, holiday decorating by family (outside). I offered to 
help in any or all of these ideas. After a few promises of action by 
the COO that were left unfulfilled all communications ceased.

I applied for job openings at the facility. I am a pharmacist and have 
during my career done medication record reviews in skilled nursing 
facilities. I learned that this required monthly reviewed of each 
patient's record had been suspended at the beginning of the lockdown. 
The process had gone virtual but with much of the record only on paper 
a full review was impossible. I applied to work in the kitchen only to 
be told by human resources even if I was allowed the job, I would be 
assigned a hallway away from whatever one Darlene or Joan was on. It 
was a comment rooted in sear meanness. I continued to apply for an 
ongoing job opening in the food service for months. I never got a 
response from anyone at the facility about it.

Darlene had some health needs that required physician visits. Each of 
these were a struggle to schedule. Even when the facility had no cases 
of COVID, Darlene's right to medical care was questioned at every turn. 
As the months of the lockdown continued this only grew more difficult. 
At a time when a single positive case in a separate hallway from 
Darlene's, and she herself had tested negative, the facility canceled a 
medically necessary appointment. They did this prior to even discussing 
it with me her POA. I was livid. I knew how essential this appointment 
was. I knew the ADON was wrong to deny it and it was not only within 
Darlene's rights to go but also critical to her health. I pleaded, I 
argued, I insisted, I requested help from the state ombudsman. My 
efforts were responded to by a threat of expelling Darlene from the 
facility by the ADON. That medical appointment was never allowed.

During these months we did window visits. We celebrated Darlene and 
Joan's birthdays with a window party. We used the iPad. We did outside 
visits when neither of them could hear us well and a monitor from the 
facility sat nearby and eased dropped on every word said. We smiled 
while there and cried all the way home. Wanting only to offer some 
happiness, some hope, some dignity to these two women that meant so 
much to us.

In November Darlene suffered a stroke. Although it was a known medical 
risk for her, I am certain it was brought on by the isolation and lack 
of hope. Studies have shown that stroke risk is increased by 32% due to 
isolation. While in the hospital emergency department I was able to be 
with her. We spent 26 hours holding hands. The facility assured me that 
she had just gotten a negative COVID test result. Within hours of her 
admission to the floor a COVID test was performed due to a slight 
fever, it was positive. With her physical health compromised by the 
stroke, she could not overcome the virus. She passed away on November 
20, 2020. The last 8 months of her life were the saddest of her 82 
years.

Joan also contracted COVID at the facility. Although no family were 
allowed access, staff of course came and went in their daily lives. One 
after another they tested positive and passed the virus to residents. 
Joan endured 2 exceptionally lonely weeks in isolation and seemed 
recovered. Within weeks staff began reporting Joan was not eating and 
was increasingly weak. The family had end of life discussions. We did 
not expect her to see the New Year. My husband and his sister applied 
for compassionate care. It was allowed. As family helped Joan eat meals 
each day her condition improved. Now 3 months later it is clear that 
her declining health in December was in large part malnutrition. 
Residents were required to eat in their rooms alone. Staff would set a 
tray in front of her which she could not functionally manage. 
Certainly, she has a small appetite at 89 years of age, but her primary 
reason for not eating was that she could not do it independently. There 
is not enough staff to feed residents in their rooms one at a time. 
This Is such a clear example of why family is essential to the health 
of loved ones in facilities.

There must be changes in the system. There are vast opportunities for 
learning from this pandemic. Please do not let stories like Darlene and 
Joan's be wasted by inaction. Long-term residential facilities for the 
elderly and the developmentally disabled of any age, need to be 
reformed. After over 30 years in acute healthcare, I know that 
caregivers at every level want to provide quality care to patients. 
Physicians, nurses, PA, CNA among others all have a role in each 
patient's care. They each deserve a workplace that recognizes the value 
they bring, provides them with a safe workplace and has policies and 
procedure that allow them to do a quality job. They need to be listened 
to. They need to be part of the change that is needed.

Families as well need to be involved. They are essential. Communication 
is such an undervalued tool to improvement. Family councils should be 
in every facility. Quarterly care plans may be sufficient in normal 
times when families are seeing their loved ones regularly. However, 
during the lockdown families should have heard from a caregiver weekly 
or more. I know hospitals that had nurses call families for updates 
daily. I find no excuses for the unanswered emails I sent to facility 
administrators. A busy schedule is no rationalization for months of 
time without response under the circumstances of the pandemic.

Facilities need to adopt principles that have guided acute healthcare 
institutions. Quality improvement, staff development, patient centered 
care principles long held by hospital systems need to be adapted by 
long-term care corporations. Residents and family that entrust them for 
care deserve no less.

Residential facilities will always be needed. Medical care cannot 
always be provided within the home. Families may not have the physical, 
emotional or financial means to care for loved ones at home. However, 
experiences and memories of the lockdown threaten the future of these 
facilities. People are renovating their homes, changing life decisions 
about care in their later years. Many facilities managed by big 
corporation are going to have to rethink their priorities to appeal to 
many again. This is the perfect time for change, real meaningful change 
that is good for residents, families and facilities.

Thank you all for your attention to the unfortunate effects the 
lockdown has had on residents and families. Please do let Darlene and 
Joan's stories be forgotten. Allow the lessons learned to lead to 
better care. Quality care that this vulnerable population deserves.

                                 ______
                                 
                   Statement Submitted by Gay L. Hull
Hi, my name is Gay Hull and my daughter Mandy Hull resides at Shapiro 
Developmental Center in Kankakee, IL. Mandy's service providers have 
shown us throughout the pandemic that they truly care about our 
daughter, but her Shapiro family cannot replace the love, affection, 
and enrichment that we provide towards her quality of life.

We have always been very involved parents. Prior to COVID we would 
travel 2\1/2\ hours, every other weekend, to spend the afternoon with 
Mandy. During these visits we would take her out to eat, shopping at 
the Mall or Wal-Mart or for long walks at local parks. We have always 
had her home during all holidays so she could spend time with her 
brother and sister and we have never missed a birthday celebration. We 
love the time that we spend with all of our children, but we especially 
cherish our time with Mandy.

Since COVID started in March of 2020, we were prohibited from visiting 
Mandy on many, many occasions. Mandy has not done well with these 
restrictions. This past year has been heartbreaking for all of us. She 
has been quarantined off and on to her room or the building. She has 
also not been able to leave her room, go outside to walk or to get some 
fresh air, spend time with her family, enjoy a variety of daily 
activities such as campus vocational training, or have access to her 
favorite foods and snacks. Her behavior has worsened because of these 
unreasonable restrictions. We feel that these restrictions have been 
cruel, inhumane, and discriminatory!

Over the past year, we have tried to do everything possible to let her 
know that we have not deserted or abandoned her . . . that we were 
still in her world, but Face Timing, phone calls, and mailed care 
packages, could not possibly replace the physical presence of her 
parents. Fortunately, we have been granted Compassionate Caregiver 
designation, thanks to the Illinois Caregivers 4 Compromise and Mandy 
is able to see us weekly, but she has NO other freedoms.

As her parents, we want safe, reasonable practices. The isolation must 
stop! Can you please help us? Thank you.

                                 ______
                                 
                    Letter Submitted by Kathy James
Dear Senators,

A year ago I spent a quiet afternoon with my then 89 year old mother in 
her assisted living facility. We watched Jeopardy together and then the 
4:00 news. At 5:00 I wheeled her down to dinner, hugged her goodbye, 
said see you tomorrow and that was the last time I would touch her even 
until today. Each day, I go to her window at the facility and call her 
on her phone to stand and talk to her. I want her to have my presence 
near so she does not feel alone. She had only been a widow for one year 
at the start of the pandemic after being married for 69 years. The 
loneliness is extreme. It is also difficult for her to get around as 
she is crippled from arthritis. She has had to manage without the help 
I would give her in keeping her room clean, watering her plants, 
putting things away. The staff can only help so much. So all the little 
things that family can do to help fall by the wayside. I was able to 
see her at a half hour visit last week and I can see her fatigue after 
just ten minutes of talking. Because she hasn't talked to anyone for 
that long in over a year. I would ask that you would take very 
seriously passing legislation so this complete lockout of families 
never has to happen again. A time limit should be allowed to get 
protocols in place and then facilities need to open to families. We 
fight not just for them but for my future and yours. I know I would not 
be able to handle what she has gone through. And many, many did not. 
They are no longer here to tell their stories.

Sincerely,

Kathy James

                                 ______
                                 
                            Justice in Aging

                    1444 Eye Street, NW, Suite 1100

                          Washington, DC 20005

                              202-289-6976

                      https://justiceinaging.org/

Justice in Aging appreciates the opportunity to submit a written 
statement for the record. Justice in Aging is an advocacy organization 
with the mission of improving the lives of low-income older adults. We 
use the power of law to fight senior poverty by securing access to 
affordable health care, economic security, and the courts for older 
adults with limited resources. We have decades of experience with 
nursing homes and other forms of long-term services and supports, with 
a focus on the needs of low-income enrollees and populations that have 
been marginalized and excluded from justice such as women, people of 
color, people with disabilities, LGBTQ individuals, and people with 
limited English proficiency.

Focus of this Statement: Breaking Through the Persistent Public Policy 
Impasse.

In the past month, Congress has convened two hearings addressing the 
need for nursing home reform: the Senate Finance Committee hearing 
(March 17th), and a hearing on Examining Private Equity's Expanded Role 
in the U.S. Health Care System, convened by the Oversight Subcommittee 
of the House Ways and Means Committee (March 25). These hearings have 
highlighted the persistently poor care provided to this country's 
nursing home residents. Unfortunately, these problems are anything but 
new.

As testimony in the Finance Committee hearing demonstrated, the COVID-
19 pandemic has exacerbated preexisting problems within nursing homes, 
including, but not limited to, inadequate staffing and slipshod 
infection prevention and control practices. The results have been 
horrific, with approximately 175,000 deaths among residents and staff 
of long-term care facilities,\1\ along with residents being isolated 
from family members and friends for an entire year.
---------------------------------------------------------------------------
    \1\ The COVID Tracking Project, The Long-Term Care COVID Tracker 
(reviewed March 31, 2021), https://covidtracking.com/nursing-homes-
long-term-care-facilities.

Many observers have suggested that now, finally, is the time for 
reforming our nursing home system. But reform is far from assured. 
Change will require that Congress break through the gridlock that has 
---------------------------------------------------------------------------
stymied nursing home public policy for several decades.

To a great extent, the public policy impasse on nursing home reform 
stems from one central dynamic: providers claim that improvement is 
impossible, due to allegedly insufficient Medicaid rates. Although they 
may concede (for example) that facility staffing levels are too low, 
they resist efforts to establish national staffing minimums, based 
largely on arguments that Medicaid rates do not support adequate 
staffing levels. As a result, nursing homes continue to staff at 
dangerously low levels, which in turn leads to resident injuries and 
death--before, during and after the pandemic.

In an effort to contribute to public policy solutions, this statement 
focuses on one important aspect of the current problem: service 
providers both a) claiming that Medicaid rates are inadequate while b) 
organizing their finances in such a way that makes it virtually 
impossible to determine appropriate rates. These counterproductive 
practices are part of the dynamic that has made nursing home reform an 
oxymoron for many years.

Nursing Home Residents Suffer Due to Inadequate Staffing Levels Linked 
to Low Wages.

Short staffing is a longstanding problem in nursing homes. A recent 
report found that 48.2% of direct-care workers earned less than a 
living wage, with approximately 56% relying in part on public 
assistance.\2\ Another study found nursing staff turnover rates of 94% 
(mean) and 128% (median) over the course of a single year.\3\
---------------------------------------------------------------------------
    \2\ Christian Weller et al., LeadingAge, Making Care Work Pay: How 
Paying at Least a Living Wage to Direct Care Workers Could Benefit Care 
Recipients, Workers, and Communities, at 8, 10 (2020) https://
leadingage.org/sites/default/files/Making%20Care%20Work%20Pay%20
Report.pdf.
    \3\ Ashvin Gandhi et al., High Nursing Staff Turnover in Nursing 
Homes Offers Important Quality Information, Health Affairs, vol. 40, 
no. 3 (March 2021), https://www.healthaffairs.org/doi/10.1377/
hlthaff.2020.00957.

Not surprisingly, poor staffing has consequences. A study mandated by 
the federal Nursing Home Reform Law determined appropriate staffing 
levels based on facility quality measures, with the recommended levels 
specific to nurse aides and nurses, and short-term and long-term 
resident stays in the nursing home. That analysis found that 52 percent 
of nursing homes failed to meet any of the recommended staffing levels, 
while a full 97 percent of the nursing homes failed to meet at least 
one of the recommended levels.\4\
---------------------------------------------------------------------------
    \4\ CMS, Appropriateness of Minimum Nurse Staffing Ratios in 
Nursing Homes; Overview of the Phase II Report: Background, Study 
Approach, Findings, and Conclusion, at 5 (2001) https://
www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/
Appropriateness_of
_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf.

Numerous studies have confirmed this common-sense conclusion: low 
staffing levels lead to poor resident care. Specific study results 
include findings that low staffing levels are connected to avoidable 
hospitalizations, more deficiencies, and poorer nurse aide 
performance.\5\
---------------------------------------------------------------------------
    \5\ See, e.g., William Spector et al., Potentially Avoidable 
Hospitalizations for Elderly Long-Stay Residents in Nursing Homes, 
Medical Care, vol. 51, no. 8, at 673 (Aug. 2013) (low staffing linked 
to avoidable hospitalizations), https://pubmed.ncbi.nlm.nih.gov/
23703648/; Nicholas Castle et al., Caregiver Staffing in Nursing Homes 
and their Influence on Quality of Care: Using Dynamic Panel Estimation 
Methods, Medical Care, vol. 49, no. 6, at 545 (June 2011) (better 
staffing linked to better quality), https://pubmed.ncbi.nlm.nih.gov/
21577182/; Nicholas Castle et al., Nursing Home Deficiency Citations 
for Safety, J. Aging and Social Policy, vol. 23, no. 1, at 34 (Jan. 
2011) (low staffing correlated to deficiencies cited by survey agency), 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878686/; John Schnelle et 
al., Relationship of Nursing Home Staffing to Quality of Care?, Health 
Serv. Res., vol. 39, no. 2, at 225 (April 2004) (higher staffing linked 
to better performance by nurse aides), https://pubmed.ncbi.nlm.nih.gov/
15032952/.

In related findings, studies also have shown a relationship between 
quality and the staffing levels for registered nurses. Current federal 
law requires only that a nursing home employ a registered nurse for 
eight hours daily.\6\ Studies have shown that higher staffing levels 
for registered nurses lead to better care for residents.\7\
---------------------------------------------------------------------------
    \6\ 42 U.S.C. Sec. Sec. 1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i); 42 
CFR Sec. 483.35(b).
    \7\ See, e.g., Mary Ellen Dellefield et al., The Relationship 
Between Registered Nurses and Nursing Home Quality: An Integrative 
Review (2008-2014), Nurs. Econ., vol. 33, no. 2, at 95 (March-April 
2015) (literature review), https://pubmed.ncbi.nlm.nih.gov/26281280/.

Not surprisingly, the ongoing pandemic has only made adequate staffing 
more consequential. Studies in both Connecticut and California found 
that higher staffing of registered nurses allowed nursing homes to 
better limit the spread of COVID-19.\8\ Also, these quality of care 
problems have fallen particularly hard on persons of color. The 
Connecticut study, for example, found greater COVID-19 spread among 
nursing homes with higher percentages of residents of color.\9\ 
Furthermore, the same principal author studied nationwide data and 
found that nursing homes with a greater percentages of residents of 
color were more likely to suffer COVID-19 cases and deaths.\10\ The New 
York Times reached similar conclusions, noting a ``striking racial 
divide'' in how COVID-19 afflicted those nursing home with high 
percentages of Black and Latino residents.\11\
---------------------------------------------------------------------------
    \8\ Yue Li et al., COVID-19 Infections and Deaths Among Connecticut 
Nursing Home Resident: Facility Correlates, J. Am. Geriatrics Soc'y, 
vol. 68, no. 9, at 1899 (Sept. 2020), https://
agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16689; 
Charlene Harrington et al., Nursing Staffing and Coronavirus Infections 
in California Nursing Homes, Policy, Politics, and Nursing Practice, 
vol. 21, no. 3, at 174 (2020), https://journals.sagepub.com/doi/pdf/
10.1177/1527154420938707.
    \9\ Yue Li et al., COVID-19 Infections and Deaths Among Connecticut 
Nursing Home Resident: Facility Correlates, at 1903, https://
agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16689.
    \10\ Yue Li et al., Racial and Ethnic Disparities in COVID-19 
Infections and Deaths Across U.S. Nursing Homes, J. Am. Geriatrics 
Soc'y, vol. 68, no. 11 (Nov. 2020), https://pubmed.
ncbi.nlm.nih.gov/32955105/.
    \11\ Robert Gebeloff et al., Striking Racial Divide: How COVID-19 
Has Hit Nursing Homes, N.Y. Times, Sept. 10, 2020, https://
www.nytimes.com/2020/05/21/us/coronavirus-nursing-homes-racial-
disparity.html#::text=the%20main%20story-
,The%20Striking%20Racial%20Divide
%20in%20How%20Covid%2D19%20Has%20Hit,the%20population%20is%20overwhelmin
gly%20
white.

Notably, provider associations acknowledge to a certain extent the 
inadequacy of current staffing practices. In a recent policy proposal, 
for example, the American Health Care Association (for-profit 
facilities) and LeadingAge (non-profit facilities) recognized the need 
for around-the-clock registered nurses.\12\ Likewise, LeadingAge 
published a report arguing in favor of paying a living wage to direct 
care workers.\13\ In each of these instances, however, provider 
associations declined to commit to actually taking these positive 
steps, which they claim must be contingent upon increased Medicaid 
reimbursement rates.
---------------------------------------------------------------------------
    \12\ American Health Care Ass'n and LeadingAge, Care for our 
Seniors Act, Improving America's Nursing Homes by Learning from Tragedy 
and Implementing Bold Solutions for the Future, at 4 (2021), https://
leadingage.org/sites/default/files/Overview%20-%20Care%20for%20
Our%20Seniors%20Act.pdf.
    \13\ Christian Weller et al., LeadingAge, Making Care Work Pay: How 
Paying at Least a Living Wage to Direct Care Workers Could Benefit Care 
Recipients, Workers, and Communities, at 30 (2020), https://
leadingage.org/sites/default/files/Making%20Care%20Work%20Pay%20Report.
pdf.

---------------------------------------------------------------------------
Nursing Homes Create Complicated Corporate Structures to Hide Profits.

The recent congressional hearings shone a light into common nursing 
home business practices that frustrate sane public policy. In 
particular, testimony submitted to the Oversight Subcommittee of the 
House Ways and Means Committee showed how nursing homes use corporate 
organizational structures to hide profits.\14\ Similarly, a recent 
academic paper demonstrated how private equity investment in nursing 
homes has led to a deteriorating quality of care, including unnecessary 
deaths, increased use of dangerous psychotropic medications, declining 
mobility, and increased expense.\15\
---------------------------------------------------------------------------
    \14\ See Written Testimony of Ernest C. Tosh, Statement of Sabrina 
T. Howell, Ph.D., and Written Testimony of David E. Kingsley, Ph.D. Mr. 
Tosh and Prof. Howell also testified in person at the hearing.
    \15\ Atul Gupta et al., Does Private Equity Investment in 
Healthcare Benefit Patients? Evidence from Nursing Homes, at 3 (Feb. 
2021). The findings of this study constitute much of the material 
presented by Prof. Sabrina Howell (one of the study's co-authors) 
during the recent hearing in front of the Oversight Subcommittee of the 
House Ways and Means Committee.

In testimony submitted to the Oversight Subcommittee, Ernest Tosh 
clearly explained the gaping holes exploited by the nursing home 
industry. First, nursing home business practices have corrupted the 
cost reporting required by CMS. As Mr. Tosh reports, ``[o]n the surface 
the financial information appears to be useful, until one realizes the 
financial picture of a single facility can be highly manipulated if it 
is within a chain of nursing homes that also contains multiple related 
corporations.''\16\
---------------------------------------------------------------------------
    \16\ Tosh Written Testimony at 2.

These cost reports may show, for example, that a nursing home has 
annual revenues approaching ten million dollars, but nonetheless is 
losing money and has relatively few assets. At first glance, such a 
nursing home may appear to be in precarious financial shape, but that 
first glance does not take into account the nursing home's many 
``related party'' transactions. The ``related parties'' are other 
corporations owned by the same persons or entities that own the nursing 
home. By contracting with the related parties to provide various 
aspects of the nursing home's operation--the building itself, for 
example, or management services, nursing services, or therapy 
services--the nursing home can claim expenses even though it is 
essentially paying itself. This allows a nursing home with few assets 
and purported annual losses to continue operating successfully: the 
overall corporate structure is profitable, even though the entity 
holding the nursing home license consistently claims losses.\17\
---------------------------------------------------------------------------
    \17\ Tosh Written Testimony at 2-6.

The written testimony of David Kingsley highlighted a related problem: 
nursing homes' frequent use of real estate investment trusts (REITs). 
REITs are used in a common type of related party transaction--the 
nursing home operator transfers the real property into a REIT, and then 
leases back the property from the REIT, claiming rent payments as 
expenses. Like all related party structures, the REITs create false 
expenses that are actually just transfers within a single corporate 
structure.\18\
---------------------------------------------------------------------------
    \18\ Kingsley Written Testimony at 2-4.

Mr. Kinsley aptly characterizes the nursing home business as ``a 
financial engineering industry engaged in trading property as a 
commodity and tax arbitrage as a core technique.''\19\ The web of 
related party transactions has no justification from a health care 
perspective. Indeed, to a significant extent, the provision of care--
and the quality of such care--is a secondary concern in such business 
models.
---------------------------------------------------------------------------
    \19\ Kingsley Written Testimony at 5.

Congress Should Provide Better Access to Medicaid-Funded At-Home Care, 
---------------------------------------------------------------------------
and Limit Nursing Homes' Use of Deceptive Corporate Structures.

We make two recommendations to improve care for older Americans in need 
of daily care. First, Congress should improve access to Medicaid-funded 
home and community-based services, so that no one is forced to live in 
a nursing home if they would rather receive necessary services at home. 
Under current federal law, a state Medicaid program must offer nursing 
home care to every qualifying person, but home and community-based 
services can be subject to a waiting list or other limit on 
enrollment.\20\ Congress should make home and community-based services 
available to all persons qualifying under Medicaid rules. Such equal 
access to home and community-based services would provide the dual 
benefit of enabling persons to receive necessary services at home, and 
give nursing homes a greater incentive to offer quality care and a good 
quality of life, in order to compete with home and community-based 
services.
---------------------------------------------------------------------------
    \20\ 42 U.S.C. Sec. Sec. 1396d(a)(4)(A) (obligation to provide 
nursing home services), 1396n(c) (home and community-based services 
waivers).

Second, as set forth in this statement, Congress should take steps to 
prohibit the financial machinations that distort the business of 
providing nursing home care. Under current business structures, many 
nursing homes are focused not on providing high quality care, but 
rather on funneling profit out of a nursing home to related parties. 
These practices penalize both residents and staff members, and 
---------------------------------------------------------------------------
inevitably lead to deterioration, injuries and deaths.

Also, as addressed above, these financial structures prevent honest 
evaluation of the adequacy of Medicare and Medicaid reimbursement 
rates. From our perspective, an increase in Medicaid rates could almost 
never be justified under current practices, because nursing home 
operators are not being forthcoming about their true financial status.

On a closely related matter, we support calls for greater transparency 
in nursing home finances, but are skeptical as to whether transparency 
alone can address the current problems. It is not realistic to expect 
CMS to perform forensic accounting on the incredibly intricate 
corporate structures in use today.

And, finally, we assert that it is entirely fair to prohibit certain 
corporate structures as a condition of Medicare or Medicaid 
certification. Nursing homes rely on public funding for the bulk of 
their revenue.\21\ Given that relationship, along with the importance 
of setting appropriate Medicare and Medicaid reimbursement rates, it 
would be eminently reasonable for Congress to prohibit the corporate 
structures that currently hamper our ability to make meaningful 
reforms.
---------------------------------------------------------------------------
    \21\ See, e.g., Medicaid's Share of Nursing Home Revenue, Resident 
Days Hits Record High as Medicare Drops to Historic Low, Skilled 
Nursing News (Dec. 11, 2019) (Medicaid and Medicare funding 
constituting over 72% of overall nursing home revenue) https://
skillednursing
news.com/2019/12/medicaids-share-of-nursing-home-revenue-resident-days-
hits-record-high-as-medicare-drops-to-historic-low/.

                                 ______
                                 
                 Letter Submitted by Lydia Nunez Landry
Chairman Wyden, Ranking Member Crapo, and distinguished Members of the 
Committee,

My name is Lydia Nunez Landry and I am writing to you today not as 
someone the American Health Care Association and LeadingAge would 
reduce to the characterization (in their ``Care for Our Senior's Act'') 
\1\ of a ``frail [or] elderly adult with underlying health conditions'' 
at risk of dying from COVID ``630 times higher than an 18 to 29'' year 
old, that is, someone these lobbyists designate as prone to death. 
Rather, despite reductions of people like me--or any other marginalized 
group--to underlying health conditions or comorbidities or biased 
stereotypes, I write to you today as an alive and thriving disabled 
woman, one who lives in and contributes to her community, and as 
someone who questions the motives of those who attribute grave 
injustice to exploited or oppressed people's own supposed deficiencies. 
Without a supportive partner to care for me in our home, I could as 
easily have died from neglect or COVID-19 in the average nursing home. 
My point here is to show that the long-term care industry is peddling 
this narrative simply to avoid responsibility for wrongdoing; that is, 
they want to pretend that people are dying in their facilities not 
because of the industry's negligence, greed, or malfeasance, but 
instead because disabled and older people have a particular tendency to 
die en masse. The narrative in ``Care for Our Senior's Act'' is yet 
another example of the industry's connivery and manipulation (I will 
append a brief example at the end of my testimony to show how they 
advance this narrative by playing with statistics).
---------------------------------------------------------------------------
    \1\ https://www.ahcancal.org/Advocacy/Documents/
Care%20for%20Our%20Seniors%20Act%20
-%20Overview.pdf.

Generally speaking, when any group of people are marked as suspect or 
inferior \2\ in some manner, when they are segregated and denied the 
resources \3\ and liberties that others enjoy, their flourishing will 
indeed be impeded,\4\ and they will be at a greater risk of contracting 
infections or disease. This is evidenced throughout history from the 
decaying and dank tenement houses of the early 19th century,\5\ the 
horrific conditions of the Warsaw ghetto,\6\ to the abuses that 
occurred in state institutions \7\ for people with disabilities. Given 
a deadly pandemic combined with deplorable (or at best unsafe) 
conditions, where people are segregated and treated as fungible objects 
from which to extract government benefits \8\ (or cheap labor), even 
AHCA and LeadingAge lobbyists like Mr. Mark Parkinson or Mr. David 
Gifford might be at a mortality risk 630 times higher than 18 to 29 
year olds not forced to endure similar circumstances. (The industry's 
claims are rarely supported by evidence, and with brief examination, 
can be shown inaccurate. Their act is at best slipshod and indicates an 
arrogance reinforced by years of overindulgence and a lack of 
accountability.)
---------------------------------------------------------------------------
    \2\ https://press.rebus.community/
introductiontocommunitypsychology/chapter/oppression-and-power/.
    \3\ https://www.who.int/disabilities/world_report/2011/
accessible_en.pdf.
    \4\ https://www.ama-assn.org/delivering-care/patient-support-
advocacy/how-racism-segregation-drive-health-disparities.
    \5\ https://socialwelfare.library.vcu.edu/issues/poverty/tenement-
house-reform/.
    \6\ https://www.iwm.org.uk/history/daily-life-in-the-warsaw-ghetto.
    \7\ https://files.eric.ed.gov/fulltext/EJ844468.pdf#page=6.
    \8\ https://prospect.org/familycare/the-corporatization-of-nursing-
homes/.

In contrast to those who are key players on K Street or spend most of 
their time in boardrooms or lobbying in the halls of Congress, I want 
to emphasize that my perspective is informed by my advocacy work in 
nursing homes where I have spent a great deal of time. I form bonds 
with residents. I know many of their spouses and children's names, 
where they were from, the hobbies they enjoyed, and the kind of work 
they did. All of this they generously shared with me. I learned what it 
was like working in a Pennsylvania textile mill in the 1930s, surviving 
a chemical plant explosion in Texas and the revolution in Cuba, and 
growing up in Mexico in the 1940s. I have heard stories from war brides 
from France and Vietnam or the time a woman had to sew thousands of 
sequins by hand on her daughter's quinceanera dress. I feel myself 
privileged to be granted the opportunity to listen. And unlike CEOs who 
earn $1,427,192 \9\ for lobbying, state ombudsman programs rely on 
volunteers. I have dedicated my life to this issue and yet rare is the 
occasion that I am asked to contribute to this topic. I--and other 
disability justice activists--have not been lavished the same platforms 
to speak given to long-term care industry CEOs and lobbyists. As a 
result of this, the voices of significantly disabled people, those at 
imminent risk of institutionalization or those in institutions, are 
squelched by the industry narrative. When I initially started out as 
ombudsman, I applied the principle of charity to the industry's 
narrative, but with careful appraisal of the incongruity between what 
residents, families, ombudsmen, advocates, experts, HHS regulators, 
CNAs, CMS, and the OIG evidenced compared to the industry's slant, it 
became apparent that industry representatives either have a deficient 
understanding of the culture and operations their business practices 
engender, or worse, they are impervious to the suffering of disabled 
people. Choosing not to see injustice or corruption, however, seems 
contrary to their lofty mission statements and commitments they have 
made to taxpayers.
---------------------------------------------------------------------------
    \9\ https://nonprofitlight.com/dc/washington/american-health-care-
association.

On occasion, circumstances force us to confront the ugliness and 
brutality that inevitably festers where we sequester vulnerable people; 
stories of abject cruelty rip away the veil of inattention we cultivate 
to block from our view the relentless mill of everyday abuse, neglect, 
and hopelessness. In these moments of outrage, we perceive the true 
nature of institutionalization and perhaps even what we must do, but 
those flashes of insights quickly fade. Soon those with vested 
interests haul out the timeworn reform narratives and ``bad apple'' 
scapegoats that persuade us to look away again, to participate in 
---------------------------------------------------------------------------
systemic neglect from afar.

As an LTC ombudsman I could not simply look away from the toll of daily 
abuse and neglect residents experience or ignore their justified 
feelings of abandonment and the despair it begets. My ombudsman work 
bears out what ought to have long been obvious to any attentive person, 
namely, that segregating people in institutions can never foster or 
indeed ever permit equal treatment.\10\ Nor--as over a hundred years of 
disability history attests \11\--can this model be fixed through 
reform. We cannot fix that which, by its nature, leads to systemic 
human rights violations. Severing people (like older and disabled 
people) from their homes and communities necessarily devalues them as 
persons and citizens. The diminishment is felt immediately. The 
freedoms they enjoyed vanish as institutional regiments constrict the 
courses of their lives. These utilitarian routines deprive them of 
their privacy and autonomy for the sake of efficiency and cost-
effectiveness. Confined in these facilities without the projects and 
relationships that endowed their lives with meaning and shaped their 
social identities, they experience a kind of social death.\12\ And so 
too their former communities, continuing on without them, lose the 
connection to them as full persons still deserving of the moral 
consideration and respect we are obliged to confer on those people in 
the community. Isolated, powerless, and dehumanized, people 
institutionalized inevitably suffer grave harms, not only from abuse 
and neglect, but from the very act of banishing them from the moral 
communities that granted the rights and benefits they are now denied.
---------------------------------------------------------------------------
    \10\ See, for example, Liat Ben-Moshe, Decarcerating Disability: 
Deinstitutionalization and Prison Abolition (Minneapolis, MN: 
University of Minnesota Press, 2020).
    \11\ Sara F. Rose, No Right to Be Idle: the Invention of 
Disability, 1840s-1930s (Chapel Hill, NC: The University of North 
Carolina Press, 2017).
    \12\ 3Jana Kralova, ``What Is Social Death?'' Contemporary Social 
Science 10, no. 3 (2015): pp. 235-248, https://doi.org/10.1080/
21582041.2015.1114407.

To be sure, congregate institutions try to simulate community to hide 
these realities, but such ersatz contrivances are no substitute for 
genuine social inclusion and belongingness; the simulations are 
parodies. Such a model cannot produce ``person-centered care'' no 
matter how many CMS regulations we enact and enforce. Nor can quarterly 
congressional hearings \13\ and regulatory tweaks \14\--informed by the 
usual actors \15\ they serve to benefit--amount to anything more than 
theater, political performances that strike those people who must 
endure the injustice \16\ as thoughtless cruelty.
---------------------------------------------------------------------------
    \13\ https://www.finance.senate.gov/hearings/a-national-tragedy-
covid-19-in-the-nations-nursing-homes.
    \14\ https://www.kxan.com/investigations/obscure-program-sends-big-
money-to-texas-nursing-homes-amid-pandemic-is-it-protecting-residents/.
    \15\ https://www.npr.org/2020/05/21/855821083/ideal-nursing-homes-
individual-rooms-better-staffing-more-accountability.
    \16\ https://www.cnn.com/interactive/2017/02/health/nursing-home-
sex-abuse-investigation/.

Only a transformative shift in public policy can end these injustices. 
This shift will require scrutinizing narratives widely considered 
axiomatic. These include the beliefs that institutionalization is an 
unavoidable consequence of aging \17\ and disability, that institutions 
provide safer \18\ environments (a claim long used to rationalize the 
barbarity of social removal despite evidence demonstrating the 
contrary),\19\ that uprooting people from the homes, communities, and 
personal identities they spent lifetimes nurturing is compatible with 
our most revered social ideals, and finally that we can outsource our 
humanity--that is, our moral and social obligations to one another, 
including our disabled parents and children--as a revenue source for 
corporations and the workers they exploit \20\ and expect humane 
results.
---------------------------------------------------------------------------
    \17\ https://www.irishtimes.com/opinion/nursing-homes-must-be-made-
a-thing-of-the-past-
1.4257422?mode=amp&fbclid=IwAR2NDUH2vj4HrwoBbpOG9iF0SYqz5RM2jTAx4BnYqVe5
MK
BBr--j6Cp6FLY.
    \18\ https://oig.hhs.gov/oas/reports/region1/11600509.asp.
    \19\ https://www.ncbi.nlm.nih.gov/books/NBK217552/.
    \20\ https://www.finance.senate.gov/imo/media/doc/
AdelinaRamos_WrittenTestimony%20
March%2017.pdf.

By now, we know these outcomes of the institutional model; it is a 
model that objectifies deeply human concerns and favors economic values 
and imperatives such as competitiveness, efficiency, and profit 
margins, values that tend to attract predatory actors.\21\ And yet we 
persist with it, and one must ask why. Why do we continue to allow 
neglect, abuse, and dehumanization to go unchecked? Why do we allow 
those same predatory actors to manufacture and control the narratives 
\22\ that frame these issues, and indeed provide them platforms \23\ in 
the halls of Congress and in the media to influence unwitting 
advocates? Why do we persist with this cultivated naivety in the face 
of so much everyday suffering? The poor human rights records of 
congregate care facilities long predate the COVID-19 crisis, but the 
crisis has laid bare \24\ the preexisting conditions that led to deaths 
of over 181,000 disabled people in these institutions.\25\
---------------------------------------------------------------------------
    \21\ https://www.nytimes.com/2021/03/13/business/nursing-homes-
ratings-medicare-covid.html.
    \22\ https://www.finance.senate.gov/imo/media/doc/
FINAL%20Dr.%20Gifford%20SFC%20
Hearing%20Testimony%203.17.2021.pdf.
    \23\ https://www.providermagazine.com/Breaking-News/Pages/AHCA,-
NCAL-Head-Parkinson-Named-a-Top-Lobbyist-for-2020.aspx.
    \24\ https://www.aclu.org/news/disability-rights/covid-19-deaths-
in-nursing-homes-are-not-unavoidable-they-are-the-result-of-deadly-
discrimination/.
    \25\ https://www.kff.org/coronavirus-covid-19/issue-brief/state-
covid-19-data-and-policy-actions/.

The horrors I witnessed as an LTC ombudsman keep me up at night, but 
also inform my disability justice work. And both my insomnia and 
activism partly derive from frustration. In deference to the industry, 
the system defangs oversight. I have fought countless nursing home 
attempts to involuntarily discharge residents only to have found that 
those residents, some with severe dementia, had disappeared the 
following week--to where, the nursing home curiously had (or at least 
offered) no clue. Sitting at their bedsides, I have held residents' 
hands as they recounted instances of rape and abuse, often by staff. 
Residents have had limbs amputated due to a lack of wound care, 
understaffing, and poor training. I have seen residents gasp for air as 
nursing home staff rationed oxygen to save money. I have called Health 
and Human Services on multiple occasions for residents due to cruel 
instances of retaliation, only to leave the residents open for more of 
the same because they sought assistance from a deliberately debilitated 
regulatory system. Finally, I, myself, have been threatened on multiple 
occasions by staff and operators. Despite my notifying HHS regulatory 
and the Ombudsman Program, nothing of substance was done. To the 
industry, ombudsmen are gnats to swat away; they well know consequences 
will not be forthcoming. After all, there are few if any consequences 
---------------------------------------------------------------------------
for the negligent deaths of residents.

Culture change is impossible within the institutional habitus, 
particularly so when professional and agency advancement, corporate 
profit,\26\ race, age, and ableism are added to the brew. From the 
institutional point of view, the dehumanizing model is working as 
intended. Hence, pumping in ever more money to fund the same solutions 
and reforms will not bring about different results. As we have seen 
during the COVID-19 pandemic, nursing homes made record profits \27\ 
from taxpayer funded COVID subsidies,\28\ yet COVID cases and deaths, 
along with non COVID deaths resulting from inadequate infection control 
practices and severe understaffing,\29\ continued to rise.
---------------------------------------------------------------------------
    \26\ http://tallgrasseconomics.org/2021/02/1539/.
    \27\ http://tallgrasseconomics.org/2021/02/the-ensign-group-
americas-biggest-nursing-home-corporation-had-a-banner-year-in-2020/.
    \28\ https://www.mcknightsseniorliving.com/home/news/assisted-
living-eligible-for-20-billion-in-new-relief-funding-for-covid-19-
related-losses-expenses/.
    \29\ https://apnews.com/article/nursing-homes-neglect-death-surge-
3b74a2202140c5a6b5cf05
cdf0ea4f32.
---------------------------------------------------------------------------
There will be no substantive change until we end the Medicaid 
institutional bias by diverting taxpayer funds away from institutions 
and to programs that maintain or reestablish community integration. As 
I often explain, nursing homes are the most subsidized \30\ industry in 
the United States and increased monetary rewards \31\ serve only to 
entrench industry malfeasance.\32\ Diverting Medicaid dollars to fund 
HCBS not only reaffirms our commitments to the Americans with 
Disabilities Act (ADA), the Supreme Court's Olmstead decision, and our 
professed democratic principles, it will also do more to soften the 
resolve of a recalcitrant industry (and similar nonprofits) than years 
of congressional hearings. In the long run, we will waste fewer 
resources on researching deficient industry practices and developing 
complex strategies to instigate change (only to be undone by 
lobbyists), on Office of Inspector General (OIG) and the U.S. General 
Accounting Office (GAO) investigations, on Ombudsman programs, on 
regulatory agencies to maintain the illusion of oversight, on 
healthcare costs resulting from the industry's negligence, and on 
subsidizing the industry's cost of doing business.
---------------------------------------------------------------------------
    \30\ http://tallgrasseconomics.org/2021/01/the-media-is-promoting-
a-dangerous-false-narrative-by-claiming-that-the-nursing-home-industry-
is-struggling-financially/.
    \31\ https://www.mcknightsseniorliving.com/home/news/assisted-
living-eligible-for-20-billion-in-new-relief-funding-for-covid-19-
related-losses-expenses/.
    \32\ https://www.youtube.com/watch?v=ee-rnrbrD1g.

---------------------------------------------------------------------------
Sincerely,

Lydia Nunez Landry
Certified Volunteer Long-Term Care Ombudsman
Organizer for Gulf Coast Adapt

Appendix:

As promised, I want to briefly review a few of the rhetorical and 
statistical practice employed by the industry and their lobbyists to 
reframe the human catastrophe exacerbated by the negligent practices in 
LTC facilities. The author of Care for Our Seniors Act,\33\ which 
aspires to learn from ``tragedy'' and implement bold solutions, 
concedes that LTC facilities were the epicenter of the ``once-in-a-
century'' pandemic's ravage. The force-of-nature language distances the 
170,000 deaths (now up to 181,286 \34\ deaths) from any culpable agent. 
And indeed, no one is to blame for the virus, just as we can blame no 
one for a major flood. But we can blame them for negligent and habitual 
substandard practices (such as not maintaining levees) that 
substantially worsen the toll. The author mentions ``independent 
research'' by ``leading experts'' which shows that ``COVID-19 outbreaks 
in nursing homes are principally driven by the amount of spread in the 
surrounding community.'' The only actual research offered \35\--
conducted in May, 2020, long before the vast majority of cased 
occurred--did conclude that size and location of facilities were 
factors while traditional metrics such as star ratings and prior 
citation for poor infection control were not. (Most of the citations 
were articles from industry magazines, one of which mentioned the 
article just cited.) It's unclear how this exonerates the industry. 
Moreover, the study, thus interpreted, becomes an outlier, as much more 
research has found direct links between poor quality ratings and 
significantly higher numbers of COVID cases and deaths (see here \36\ 
and here \37\).
---------------------------------------------------------------------------
    \33\ https://www.ahcancal.org/Advocacy/Documents/
Care%20for%20Our%20Seniors%20Act%
20-%20Overview.pdf.
    \34\ https://www.kff.org/coronavirus-covid-19/issue-brief/state-
covid-19-data-and-policy-actions/.
    \35\ https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/
jgs.16661.
    \36\ https://www.sciencedirect.com/science/article/abs/pii/
S0195670121000086.
    \37\ https://www.sciencedirect.com/science/article/pii/
S1525861020305211.

Instead of dueling studies, we might focus on statistics. The author 
notes another force of nature behind the deaths, namely time: aging and 
the fragility of bodies. The virus just happens to target the frail and 
elderly adults with underlying health concerns that live in their 
facilities. The author incorrectly asserted that the average age of 
nursing home residents is 85, but correctly asserted that most 
residents have underlying conditions, as indeed most people over 65 
years old have multiple chronic conditions, in and out of LTC 
---------------------------------------------------------------------------
facilities. First some number:

The U.S. has approximately 52 million citizens aged 65 or greater. Of 
them, 430,000 have died from complications of COVID-19 infections. Of 
those, 130,000 died in nursing homes--the author mention 170,000 
deaths, but that includes congregate facilities the data from which is 
sparse, so I shall stick with the 130,000 in nursing homes (NHs). Thus, 
300,000 died elsewhere than a NH. NHs warehouse approximately 1.4 
million residents, 90% of whom are 65+ years old. The total number of 
cases in NHs is, at the moment, 643,314, and, for non-NH people in the 
same age group, 2,666,625. Looking at the bare infection and death 
numbers, one might think that nursing homes did well--too well, in 
fact, for the author's contentions.

But consider again that most people over 65 years old have chronic 
conditions and most people, even with their bleach wipes, have 
rudimentary infection controls in their homes. Now, 9.28% of the 1.4 
million people in NHs have died from COVID; we can round that up to 1 
in every 10. But if non-NH people in the same fragile age group died at 
that rate, we would have an incredible 4,342,857 more deaths than we 
do, as only 1 in 167 non-NH elderly people died from COVID. Indeed, 
examining only those infected, you are nearly twice as likely to die 
(20% vs. 11%) if you're in a NH than not. Indeed, the infection rate in 
NHs is 46% vs. 5.3% for non-NHs fragile people.

Now, ultimately, industry spokespeople will claim that the deaths 
occurred because all these people are interacting in close quarters, 
and so on. But this is not something that can be fixed, and so it 
underscores why we need to turn back to community integration instead 
of warehousing people in admitted death traps.

                                 ______
                                 
                               LeadingAge

                      2519 Connecticut Avenue, NW

                       Washington, DC 20008-1520

                             P 202-783-2242

                             F 202-783-2255

                             LeadingAge.org

Thank you for the opportunity to comment on the above hearing. Our 
members and the older adults they serve have been irrevocably affected 
by this pandemic. We appreciate the concern that this Committee has 
expressed over the past year and its efforts to address the significant 
challenges posed by both public and private responses to the public 
health emergency.

LeadingAge is a tax-exempt national organization focused on education, 
advocacy, and applied research. The mission of LeadingAge is to be the 
trusted voice for aging. Our 5,000+ not-for-profit members include the 
entire field of aging services providers--nursing homes, home care and 
hospice, affordable housing, life plan/
continuing care communities and assisted living.

We begin our statement by asking the most difficult question, what 
happened?

If only it were easy--if only there was an answer to the question, what 
happened? Why did so many people die in nursing homes? What magic 
bullet could we have fired to prevent this? What magic bullet can or 
should we look to in the future?

As Dr. Tamara Konetzka testified, based on her rigorous, highly 
respected research, ``the two strongest and most consistent predictors 
of worse COVID-19 outcomes are nursing home size, with larger 
facilities being more at risk, and COVID-19 prevalence in the 
surrounding community,'' as opposed to star rating, staffing, access to 
PPE, etc.\1\ The greater the presence of the disease in the community, 
the greater the impact on residents and staff. The second condition is 
something that we have tolerated for many years--large poorly funded 
nursing homes with many residents, many of the long-stay residents poor 
and racial minorities, again, at greater risk for this disease for all 
the reasons that we know as we attempt to address the impact of 
centuries of discrimination. In those communities with the highest 
spread, where staff are as affected as residents, the disease was at 
its deadliest.
---------------------------------------------------------------------------
    \1\ We appreciate that there is research showing that nonprofit 
nursing homes and nursing homes with higher rankings, many of whom are 
our members, fared better. However, they too faced all the public 
health challenges we discuss, herein, and without addressing those 
challenges, we consign all nursing homes, even the best performers, to 
an intolerable situation.

When Dr. Kontezka was asked, what could have been done to reduce this 
tragedy, she responded, better use of public health to control spread 
in the community We needed a fast, all of government public health 
---------------------------------------------------------------------------
response to contain and control the disease and that did not happen.

This pandemic was a failure of our public health infrastructure, and 
that failure trickled down to infect all the public and private health 
care and housing entities that supported at risk populations, both 
residents and staff.\2\
---------------------------------------------------------------------------
    \2\ We note that the negative impact of the pandemic on older 
persons and persons living in nursing homes and other congregate 
settings, along with public and private response, is not limited to the 
United States. A survey conducted by Global Ageing Network, 
representing aging services providers throughout the world, revealed 
eerily similar experiences. https://globalageing.org/gan-covid-report/.

The underlying challenge to this disease--its very newness--was faced 
by all our members. It is called the novel coronavirus for a reason. 
Each day brought new knowledge about the disease, but that means that 
the day before, we were operating on old and not necessarily accurate 
information. For example, during the early days when the pandemic was 
new--March and April 2020--a lack of understanding of how the disease 
spread resulted in inconsistent and often changing advice (e.g., when 
to use masks; testing limited to symptomatic staff and residents, 
before we realized it was spread asymptomatically and was not 
contained; inconsistent directives from state, local and federal public 
---------------------------------------------------------------------------
health authorities).

In addition, the entire health care system was left to fight it out for 
essential supplies rather than having a centralized source (indeed, 
even FEMA couldn't adequately fulfill the White House's April directive 
to send 2 weeks of supplies to nursing homes months into the pandemic.)

Failure of public leadership to understand the disease led to new 
problems placed at the feet of nursing homes trying to follow the ever-
changing directives--e.g., closing down nursing homes to visitors saved 
lives (because of asymptomatic carriers, speed with which older persons 
died from infection) but because we had NO idea how long the crisis 
would last, created its own secondary health crisis, isolation.

Why is it so important to stress the public health failures? Because we 
must learn the right lessons if we are not going to repeat this 
disaster as this public health emergency continues and we also examine 
how to avoid future disasters.

To fix public health infrastructure in the future we must have:

      Transparency and honesty; credibility of public and private 
systems can only be built on a foundation of transparency and open 
communication, even but perhaps most importantly when we do not have 
answers.
      National public reporting system to ensure accuracy and 
consistency, including reporting of race, ethnicity, gender and age.\3\
---------------------------------------------------------------------------
    \3\ See, e.g., LeadingAge's letter to Sec. Azar asking for a 
uniform reporting system. file:///C:/Users/Marsha/Documents/
CDC%20reporting%20letter%20final.pdf.
---------------------------------------------------------------------------
      National testing strategy to eliminate duplicative, 
contradictory policies; and public financing to ensure that private 
entities are adequately compensated for mandatory requirements.\4\
---------------------------------------------------------------------------
    \4\ See, e.g., LeadingAge's letter to Congressional leadership, 
file:///C:/Users/Marsha/Downloads/Testing%20letter.pdf.
---------------------------------------------------------------------------
      Public access to PPE, to eliminate the ``hunger games'' scenario 
where providers are mandated to use PPE but PPE is in short supply 
globally, leaving providers to find PPE by themselves, hoping their 
standard supplier has access or they can find some other supplier who 
is reliable and honest. Public access would also reduce the problem of 
price gouging, where the cost of a disposable gown increases from 25 
cents pre-pandemic to $4.00 during the pandemic. It truly is the 
federal government's responsibility to manage access to and 
distribution of rare but life-saving essential products.
      Emergency preparedness infrastructure must include aging 
services. Examples include retaining the strike teams that some states 
created earlier in the pandemic (and now funded though CMS); and 
effective use of the public health workforce to supplement workers who 
are in quarantine or sick leave. This is essential not only for nursing 
homes but all congregate and senior housing, including HUD housing 
where low-income seniors at highest risk live in the ``community'' but 
with little access to necessary services (e.g., Wi-Fi, access to 
testing and vaccines). Aging services providers must be at the table at 
all levels. This is the lesson we thought was learned from Katrina, but 
it is not clear we did.
      Telehealth/technology/broadband issues of fairness and access 
remain. We clearly need to improve broadband access in rural areas; 
provide access to reduced rates for rural home health providers as we 
do for nursing homes; reimburse telehealth capabilities in non-rural 
nursing homes and other care settings; and address access and 
availability in community settings, for example by allowing HUD housing 
providers to wire their apartment buildings for Wi-Fi for tenants.
      Effective public/private partnerships. The long-term care 
pharmacy partnership to deliver vaccines to almost every nursing home 
is a good example of the federal approach that has been sorely missing. 
While not perfect, with improvements it could be a model for addressing 
specific needs in future emergencies.

The second cause identified by Dr. Konetzka--large poorly funded 
nursing homes--embodies long-standing challenges to the way we deliver 
long-term services and supports. To address these issues, we must:

      Focus on long-stay residents--financed through Medicaid and to a 
much smaller extent, private pay--and rebuild our communities to 
address the social and health needs of these residents.
      Rethink how nursing homes are conceived and structured, moving 
to a smaller setting, with single rooms, again focusing on the needs of 
long-stay residents;
      Address workforce issues; the continual shortage of qualified 
staff at all levels and the serious underpayment especially at the 
direct care worker level must be addressed; LeadingAge's Center for 
Workforce Solutions \5\ and the LeadingAge LTSS Center@UMass \6\ are 
both dedicated to identifying solutions to these issues.
---------------------------------------------------------------------------
    \5\ https://leadingage.org/workforce.
    \6\ https://www.ltsscenter.org/.
---------------------------------------------------------------------------
      Address critical financing issues associated with under-payment 
from Medicaid and the negative impact that underpayment has on quality 
and services. LeadingAge members regularly report that they must raise 
millions of dollars annually through charitable donations to provide 
high quality care because of underfunding from Medicaid.
      Recognize that nursing homes are part of a continuum of services 
primarily financed by public programs. We critically need a non-means 
tested public long-term care insurance program to ensure that all 
persons have an affordable means of paying for long-term care, are able 
to age or live with disability in the setting of their choice for as 
long as they can, with both quality of life and quality of care.

In addition, witnesses at this hearing and at other hearings before 
this committee and the Special Committee on Aging have raised concerns 
about how to ensure nursing homes provide high quality care, and how to 
respond to nursing homes that are poor performers.

Care for Seniors, the 8 point program LeadingAge and AHCA have put 
forward, addresses many of the concerns raised during this hearing, and 
identifies public and private financing mechanisms to implement these 
policies.\7\
---------------------------------------------------------------------------
    \7\ https://leadingage.org/care-our-seniors-act.

    1.  To enhance quality of care:
        a.  Enhanced Infection Control: we strongly agree that 
infection control is critical and have proposed updating the current 
guidelines to address some of the challenges around workforce and 
training to make it possible to employ infection control specialists in 
each nursing home.
        b.  RN 24/7: many of our members already employ registered 
nurses on a round-the-clock basis. In many parts of the country, 
however, there is a shortage of qualified nursing staff, and Medicaid, 
the primary payer for long-stay nursing home residents, is not funded 
in a way that covers current costs, much less the addition of, in 
effect, 6 full time nurses just to have one nurse on staff all the 
time. We provide a number of recommendations on how to implement 
expanded staffing.
        c.  Maintaining a minimum 30-day supply of PPE, to address 
current and future infectious diseases and other conditions that 
require extensive protective equipment. Again, this will require not 
just action by nursing homes but also a commitment from the public 
sector to ensure that adequate supplies are available continually.

    2.  Recruit and Retain a Long Term Care Workforce Strategy:
        a.  For decades the nursing home field has been plagued by 
shortages in staff, whether because it is easier and more lucrative to 
work in settings like hospitals, as Ms. Ramos so accurately testified, 
or because there simply are not sufficient numbers of persons 
interested in this field. As mentioned above, LeadingAge's Center for 
Workforce Solutions and LTSS Center have been working on attracting 
workers for many years, culminating in the ground-breaking work, Making 
Care Work Pay, which addresses the economic benefits and necessity of 
providing a living wage, along with the challenges of implementing this 
policy.
        b.  Care for Seniors recommends a multi-phase tiered approach 
to supply, attract and retain the long term care workforce, including 
leveraging federal, state, and academic entities to provide loan 
forgiveness for new graduates who work in long term care, tax credits 
for licensed long term care professionals, programs for affordable 
housing and childcare assistance, and increased subsidies to 
professionals' schools whose graduates work in nursing homes for at 
least 5 years.
    3.  Improve Systems to be More Resident-Driven
        a.  Survey Improvements for Better Resident Care: Over many 
years, numerous studies by private and public entities have documented 
failures in the survey system, from inconsistent results to failure to 
identify and fix significant deficiencies. This over 30-year old system 
needs to be revamped to reflect modern thinking on addressing medical 
errors (e.g., using the elements in the patient safety model) and the 
significant changes in nursing homes and the residents we serve since 
this system was inaugurated in 1987. LeadingAge strongly supports the 
study currently undertaken by the National Academies of Science, 
Engineering and Medicine (NASEM) reexamining the current way we 
identify, measure and enforce quality of care and quality of life in 
nursing homes.\8\ Additionally, Care for Seniors makes recommendations 
that support development of an effective oversight system and processes 
that support improved care and protect residents.
---------------------------------------------------------------------------
    \8\ https://www.nationalacademies.org/our-work/the-quality-of-care-
in-nursing-homes.
---------------------------------------------------------------------------
        b.  Chronic Poor Performing Nursing Facilities and Change of 
Ownership: A corollary of the failure of the current survey and 
certification system is the continued and seemingly intractable problem 
of chronic poor performers. LeadingAge supports the Nursing Home Reform 
Modernization Act (S. 782) introduced by Senators Casey and Toomey as 
an excellent example of a creative way to address improving care by 
creating a separate program within CMS to provide mandatory counseling, 
education and assistance for poor performers. In Care for Our Seniors, 
we propose a detailed process for working with poor performers: (1) 
Identify chronic poor performing facilities; (2) Conduct an analysis to 
determine the reason for chronic poor performance; (3) Develop a turn-
around plan; (4) Monitor progress; and (5) Determine if the plan of 
correction goals have been met or the need for plan revisions. Finally, 
we ``bite the bullet'' and state, ``If milestones are not met within 
six to 24 months (median time of one year), a temporary manager, change 
in management/ownership or the closure of the facility may be 
required.''
        c.  Customer Satisfaction: As we note in this last 
recommendation, nursing homes are the only Medicare health care 
provider that does not include customer satisfaction in the data 
collected and reported by CMS. Hospitals, hospice, and home health 
collect customer satisfaction, which is part of their publicly reported 
data. We recommend adding a customer satisfaction measure to the 5-star 
rating system, to help consumers and family members monitor the quality 
of nursing homes.

Finally, we should use this crisis as an opportunity to think more 
broadly about how we want to age, what services we will need in the 
future, how we will want to live, and how we expect to finance the 
aging services ecosystem. While we understand the importance of 
addressing care in nursing homes during the pandemic, we would note 
that more older adults live in the broader community than in nursing 
homes. We have very little data on the impact of COVID on older adults 
who receive LTSS in the community.

We must, therefore, also address loss of community-based services. 
Closure of adult day programs, PACE, senior centers, loss of access to 
HCBS and home care workers all had a negative impact on seniors now and 
will in the future. LeadingAge members who provide home-based care, 
whether through Medicare, Medicaid or private pay, had trouble 
accessing PPE, testing, and vaccines, which would be essential to their 
being able to serve their clients. The adults we serve as well have had 
difficulty being prioritized for testing and access to vaccines, 
especially home-bound clients. In this respect, a more robust public 
health infrastructure, with community mobile clinics, is critical, as 
well as addressing the needs of individuals in HUD-supported housing.

In conclusion, we thank you for the opportunity to engage in this very 
critical endeavor, improving the care and services our provide to the 
most vulnerable and frail in our society. This pandemic has been 
devastating to the people we serve, our staff, and our leadership. We 
must learn the right lessons so that we are able to come out of this 
crisis stronger and able to provide older adults with true quality of 
life and services.

                                 ______
                                 
                  Letter Submitted by Carrie Leljedal
A National Tragedy: COVID-19 in the Nation's Nursing Homes

Wednesday, March 17, 2021

To: Senate Committee on Finance

Thank you for allowing me to submit a statement in regard to the COVID-
19 crisis in Skilled Nursing Facilities (SNF) in the United States. My 
name is Carrie Leljedal, and I have a 33-year-old son who resides in an 
Intermediate Care Facility for adults with Developmental Disabilities 
(ICFDD), Skilled Nursing.

I am also the leader for Illinois Caregivers for Compromise, we 
advocate for residents and families in all kinds of residential long-
term care facilities (LTCF) in Illinois, and with our National Chapter. 
Recently, I started volunteering with the Illinois Ombudsman office.

When most families must deal with long-term care it is for less than 5 
years. I am in this for the long haul, my son will always require 
skilled nursing he has resided in his facility for seven and half years 
and could easily be there another 40-50 years.

My Lynn, was born with a rare seizure disorder, called Sturge-Weber 
Syndrome (SWS) and a host of other serious health conditions. Lynn has 
had over 100 surgeries in his life, and close to 45 hospital stays. 
Lynn is currently followed by three different kind of neurologist, 
three different eye doctors, two endocrinologist, one GI doctor along 
with both physical and psychologist therapist. One of the biggest 
issues we face early on into the pandemic was we had to cancel all of 
Lynn's doctor's appointment.

Lynn has lived in his ICFDD in Southern, Illinois. On March 9, 2020, I 
received a call from the Executive Director telling me that the county 
health department was restricting all visitors to the facility. Five 
days later, CMS issued guidance on March 13, 2020 to shut down all 
facilities to anyone who was not employed at the facility.

I had seen Lynn on March 9th and was unable to see him again until late 
June, I do not consider virtual, or window visit a visit to see my son. 
When I finally was able to see my son, it was only at doctors' 
appointments and I was required to stay 6 feet away, socially 
distanced. When I met him at his ICFDD, for his first post quarantine 
doctor's appointment the ED came outside and informed me that I was not 
allowed to hug or kiss my son, I was an inch shy of fully 
hyperventilating while driving to follow them to the doctor's 
appointment. Explaining to my son, why I could not hug or kiss him was 
exceedingly difficult for both of us.

In a years' time, my son has been able to come home for three different 
long weekends, when returning to the ICFDD, he was required to 
quarantine for 14 days. I have been told, that would continue even 
though he is fully vaccinated and so are my husband and myself.

Residents of LTCF, have suffered in ways that will take us years to 
fully understand. The fear of the unknown might have been one of the 
hardest parts of this. My son is verbally high functioning and 
understands things well, as much as he understood why he had to be 
quarantined it still affected him mentally and physically. Early on as 
COVID first entered the building, my son would ask me if I knew which 
of his friends had tested positive and if anyone had died. Never did I 
think this would be a regular question from my son. Explaining all of 
this to an adult who functions at around a 10-12-year-old level was 
quite difficult.

CMS issued some visitor guidance on September 17th, the guidance was 
extremely limited, but it was a start, until the states got their hand 
on it. As the leader of the Illinois Caregivers for Compromise, I heard 
from members all over Illinois and with leader of the other states. CMS 
guidance did little to nothing to assist residents with being able to 
see their family members. Many states would only allow for 
compassionate care visit, at end of life and still required family 
members to remain socially distanced from their loved ones. The number 
of people that have died alone in the US over the past year, because 
hospitals and long-term care facilities would not allow family members 
to remain until the end is unfathomable.

September 17th guidance allowed for outside visits for residents and 
family members. This was set up to fail on day one. By the time you 
require 6 ft social distance and barrier and masks between the resident 
and the visitor, most residents could not hear the visitor and or 
recognize them.

The director of Nursing Homes Division for CMS, Evan Shulman, has 
publicly stated multiple times that he has heard from residents that 
they would rather die from COVID-19 than go another year without seeing 
family.

The effects the isolation has caused on residents of all kinds of long-
term care facilities in the United States is cruel and unusual 
punishment. Why are we punishing some of our most fragile residents in 
the United States, who need extra care to live.

Are you aware that long term care effects every age? There are children 
who can spend years in long term care because they require more medical 
care than a parent can provide at home, but not enough to keep them in 
a true hospital setting. Adults with developmental disabilities (DD) 
usually enter long-term care in their late teens or early twenties and 
remain there the rest of their lives. Even residents of adult DD 
community living arrangements have been isolated from their families 
this last year.

Early in the pandemic, the mandated quarantine of residents on any kind 
of long-term care facility made sense. One we where past the first few 
months and had reliable testing and PPE the residents should have had 
as many of their rights restored as possible. Residents of long-term 
care are entitled to the same freedom and right to make their own 
choice as any other resident of the United States. There could have 
been many ways to restore some of the resident's rights to allow some 
visitors, using common sense and core safety protocol, while treating 
residents and family members with respect and not like guilty 
criminals.

A year later, with new visitation guidance in place that does allow for 
visitation and physical contact, most facilities and quite a few States 
are making their own rules and in turn they continue to violate the 
resident's rights. If I had to guess over 50% of residents in long-term 
care have not seen a family member or friend in over a year without a 
window between them and a supervised visit as if they where in prison.

There are so many things that have gone wrong over the past year in 
long term care, we all know that the entire system from pediatrics to 
geriatrics needs a complete overhaul. To do this and to do it right, 
you need all stake holders at the table. The fact that there was not a 
single resident or family members asked to give testimony during the 
public hearings speaks volumes as to where they stand.

In Missouri and Illinois, CMS issued penalties to 258 nursing homes 
during 2020 and earlier this year for infection control deficiencies. 
Of those, 220 also received incentive payments for low COVID-19 
transmission rates.

The largest infection control-related penalty for any nursing home 
across the two states in 2020 went to Life Care Center of St. Louis. 
CMS issued a penalty of almost $500,000 in May for issues that 
inspectors said ``placed all residents in the facility in immediate 
jeopardy.''\1\
---------------------------------------------------------------------------
    \1\ https://www.medicare.gov/care-compare/inspections/pdf/nursing-
home/265610/health/infection-control?date=2020-05-18.

So far, Life Care Center has reported eight residents' deaths due to 
---------------------------------------------------------------------------
COVID-19 to CMS.

In October, the facility received nearly $60,000 in incentive payments.

At Crystal Creek Health and Rehab Center in Florissant, 13 residents 
died of COVID-19. For infection control deficiencies in February and 
September 2020, CMS issued a $153,842 penalty. The next month, Crystal 
Creek received an incentive payment from HHS. By December, the 
incentive payments totaled $146,088, almost completely wiping out the 
penalty.

Across Missouri and Illinois, almost 200 nursing homes received 
incentive payments that were greater than their infection control-
related penalties from 2020 or 2021.

A statement from the Health Resources and Services Administration, 
which administers the incentive program, said that there are two 
criteria for an actively certified nursing home to receive an incentive 
payment: ``First, a facility must demonstrate a rate of COVID-19 
infections that is below the rate of infection in the county in which 
they are located. Second, facilities must also have a COVID-19 death 
rate that falls below a nationally established performance threshold 
for mortality among nursing home residents infected with COVID-19.''

However, the calculations for the incentive payments do not take into 
account \2\ whether a facility has a previous or ongoing deficiency 
from a CMS inspection.
---------------------------------------------------------------------------
    \2\ https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/
nursing-home-qip-methodology.pdf.

Instead of giving bonus payments to the nursing homes, they could have 
used those monies to require more staff to be hired and people given 
---------------------------------------------------------------------------
jobs and the residents would be safe.

An HRSA statement said the incentive money must be spent in certain 
ways: ``Nursing home QIP recipients must utilize the resources they 
receive to continue to protect their residents and staff against this 
devastating pandemic and they must attest to the terms and conditions 
outlined in the program for payment. For example, quality incentive 
payments may be used for costs associated with administering COVID-19 
testing for both staff and residents; reporting COVID-19 test results 
to local, state, or federal governments; hiring staff to provide 
patient care or administrative support; efforts to improve infection 
control, including activities such as implementing infection control 
'mentorship' programs with subject matter experts, or changes made to 
physical facilities; and providing additional services to residents, 
such as technology that permits residents to connect with their 
families if the families are not able to visit in person.''

We need a complete overhaul of the long-term care system in the United 
States. The priority must be quality of life for the residents. The 
fact that we have lost over 150,00 residents in Long-Term Care due to 
COVID-19 proves we can not protect than from COVID. The number of 
people who died from Isolation, Failure to Thrive, Neglect and Abuse 
might never been know, but by protecting them to death we took away any 
quality of life that they might of had.

I am begging all of you, put yourself in my shoes, imagine knowing your 
child will live in long-term care for another 40-50 years, would you 
want them to go through another year like 2020. If we can find a way to 
bring the right people to the table, we can find a way to better the 
system to prevent anyone from having to relive 2020.

Sincerely,

Carrie Leljedal

                                 ______
                                 
                  Statement Submitted by Ja'Nisa Mimbs
My Mother is in Eastview Nursing Center in and we've not been allowed 
to touch or spend any valuable time with her since February 19, 2020. 
We've visited at her window, which they refuse to even crack for her to 
hear us. Then they started these outdoor visits for 30 minutes. Keep in 
mind, it was on Tuesdays and Thursdays from 9:00 a.m.-10:00 a.m. and 
4:00 p.m.-5:00 p.m. That's eight visits a week for the entire nursing 
home, you had to make a reservation and pray you got a spot. The visits 
were outside with a table between us and an aid watching our every move 
to ensure we didn't touch her. They stopped those visits in September 
and just started them back on March 1, 2021.

My Mother was walking with a walker, dressing herself, using the 
restroom, feeding herself and needed little assistance with her daily 
activities. In October she started to decline, she had a severe UTI 
that had gone unnoticed by the staff and as we weren't allowed to spend 
anytime with her, we couldn't alert them that something was wrong. By 
the time it was caught, it was severe! She was very confused, was 
incontinent and in a diaper. Something she'd never been before. They 
gave her the antibiotic Vancomycin intravenously and it was so strong 
it almost killed her. She was so weak and she's never come back from 
it. This was the start of her decline in October, we were never allowed 
Compassionate Care Visits to try to boost her spirits and entice her to 
improve. Yet they tell us she's depressed, not eating and they're 
putting her on an antidepressant. At this point she was not walking, 
any longer and was placed in a wheelchair. She was moving herself 
around in her chair with her feet and was still getting up every day. 
Then it got to where they were leaving her in her wheelchair all day 
while she's complaining that her bottom hurt and we now have a bedsore 
on her bottom. Thanksgiving Day we visited at her window and they 
allowed me to give her a plate of banana pudding, she sat and fed 
herself the entire plate. Many visits at her window in the cold with my 
78-year-old stepfather is all we had. Christmas Day, again, a plate of 
food, she fed herself and by mid-January she was bed ridden, she's now 
in the bed being turned every 2 hours from side to side to help the 
bedsore, she's 90 pounds, now on pureed foods, being fed and can do 
nothing for herself not even hold a cup of water. We've signed the 
paperwork as last week (March 8, 2021) to put her on Hospice, at the 
advice of the nursing home physician and we're still not being allowed 
Compassionate Care Visits.

We can do the 30-minute visits which they make her get in a geriatric 
chair while she complains that it hurts her bottom. We've asked the 
administrator about Compassionate Care Visits and were told, they will 
do them on Mon., Wed., Thurs., Fri. between the hours of 11:00 a.m. and 
4:00 p.m. We must allow the staff to administer a rapid antigen COVID 
test, be dressed in full PPE gear (head to toe) and can't touch her, 
only sit 6 feet from her in her room, but these have not been arranged 
yet. While the staff come and go as they please with nothing but a mask 
on.

Also, she's in a room by herself, she's basically quarantined already 
and we still can't see her, touch her or speak to her without the staff 
monitoring us.

My Mother deserves so much more, all the residents do. Without family, 
what quality of life do they have? They've lived their lives and their 
only comfort is family and that has been snatched away as they're 
treated like hostages and I never thought this world would come to me 
having to beg for permission to hug my Mother, care for her, sit by he 
side and hold her hand while she leaves this cruel world!

                                 ______
                                 
       National Consumer Voice for Quality Long-Term Care et al.

                 1001 Connecticut Avenue, NW, Suite 632

                          Washington, DC 20036

                            Ph: 202-332-2275

                           Fax: 866-230-9789

                        www.theconsumervoice.org

                                          Jonathan Evans, President
                                  Lori Smetanka, Executive Director
March 29, 2021

U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200

RE:  Statement for the Record: A National Tragedy: COVID-19 in the 
            Nation's Nursing Homes; Hearing before the U.S. Senate 
            Committee on Finance March 17, 2021

Dear Chairman Wyden, Ranking Member Crapo, and Members of the 
Committee:

The National Consumer Voice for Quality Long-Term Care, Community Legal 
Services of Philadelphia, and the Michigan Elder Justice Initiative 
would like to thank Chairman Wyden and Ranking Member Crapo for holding 
this hearing on the devastating impact of the COVID-19 pandemic on 
nursing home residents

Our organizations advocate for quality care, quality of life, and the 
rights of nursing home residents and other long- term care consumers. 
We appreciate the opportunity to share our input on this critical issue 
with the Committee.

No group of Americans has suffered from COVID-19 more than nursing home 
residents. Over 130,000 \1\ residents have died from COVID-19, while 
over 1.1 million residents and staff have been infected.\2\ At the same 
time, countless others have suffered from isolation and neglect. An 
Associated Press article \3\ from November 2020 estimated that there 
had been over 40,000 excess deaths in 2020 compared to 2019 that were 
not attributable to COVID-19. That number is likely much higher now. 
Adding to the suffering, one year after nursing homes were locked down, 
tens of thousands of nursing home residents continue to have extremely 
limited, if any, in-person contact with their families and loved ones.
---------------------------------------------------------------------------
    \1\ https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-
xpvg/.
    \2\ Both numbers are an undercount. CMS did not require nursing 
homes to start reporting data regarding COVID-19 cases and deaths until 
May 8, 2020 and did not require facilities to report COVID-19 data back 
to the beginning of the pandemic. Other totals, such as The New York 
Times, are much higher. However, the Times total includes all long-term 
care facilities, for instance, assisted living facilities, and not just 
nursing homes.
    \3\ https://apnews.com/article/nursing-homes-neglect-death-surge-
3b74a2202140c5a6b5cf05cdf0
ea4f32.

These numbers are even more tragic because much of this suffering and 
death could have been prevented. Years of insufficient staffing and the 
nursing home industry's focus on profits over residents, combined with 
the slow and inadequate federal response to the pandemic in long-term 
care facilities created a perfect storm resulting in tragedy. COVID-19 
has also exposed the failures of nursing homes to care for and protect 
residents adequately. Without significant policy changes, long-standing 
problems will continue, future pandemics will be equally devastating, 
---------------------------------------------------------------------------
and residents will be the ones who suffer and die.

We urge Congress to:

      Initiate an investigation into the devastating impact of COVID-
19 on nursing home residents.
      Support nursing home staff by requiring minimum staffing 
standards, training, and increased wages and benefits.
      Require the rescission of all waivers of nursing home 
regulations established during the Public Health Emergency.
      Ensure access to COVID-19 vaccines for all residents and staff 
who choose to be vaccinated.
      Ensure protection from COVID-19 for residents and staff by 
ensuring ongoing access to PPE and testing.
      Fully restore visitation in nursing homes.
      Reinstate standard and complaint surveys and strengthen 
regulations and enforcement.
      Require transparency and accountability around nursing home 
ownership and finances.
      Address disparities in care for racial and ethnic minorities.
      Expand choice through the expansion of Medicaid Home and 
Community Based Services.

Many of these recommendations will have the immediate effect of 
preventing further harm from COVID-19 while also having the long-term 
benefit of increasing the overall quality of care and preventing a 
recurrence of the devastation wrought by COVID-19 in the future.

I.  Investigate the Full Impact of the COVID-19 Pandemic on Residents 
of Long-Term Care Facilities, Including the Disproportionate Impact on 
People of Color

Before the pandemic, 82% of nursing homes in the United States had been 
cited for an infection control violation, with 50% of those homes 
having repeated problems.\4\ The deadly impact on nursing home 
residents from infections has long been known. Infections have been a 
leading cause of morbidity and mortality among nursing home residents, 
with 1.6 million to 3.8 million infections per year before the 
pandemic.\5\ Yet, many nursing homes were utterly unprepared to prevent 
the spread of infectious disease among residents. In August 2020, five 
months into the pandemic, former CMS Administrator Seema Verma noted 
that nursing home inspections continued to find widespread failures in 
basic infection control procedures, such as handwashing.\6\
---------------------------------------------------------------------------
    \4\ https://www.gao.gov/products/gao-20-576r.
    \5\ Richards, C. Infections in residents of long-term care 
facilities: An agenda for research. Report of an Expert Panel. 50 JAGS. 
570-576 (2002).
    \6\ https://skillednursingnews.com/2020/08/cms-targets-infection-
control-in-new-nursing-home-training-program/.

From the outset, the industry has asserted that since COVID-19 rates in 
the community heightened the risk of spread in the facility, there was 
little it could do to protect residents. This claim has been proven 
inaccurate by numerous studies that show that similarly situated 
nursing homes that invested in staffing and care quality did better 
than homes that did not.\7\ Recently, the New York Attorney General 
released a report \8\ finding that a facility's prior history of 
inadequate staffing was more predictive of outcomes than other factors, 
including its geographic location.
---------------------------------------------------------------------------
    \7\ Figueroa, J.F., Wadhere, R.K., Papanicolas, I., Riley, K., 
Zheng, J., Orav, E.J. and Jha, A.K.. Association of nursing home 
ratings on health inspections, quality of care, and nurse staffing with 
COVID-19 Cases. JAMA: (2020): August 10, E1-E2; He, M., Li, Y., and 
Fang, F. Is there a link between nursing home reported quality and 
COVID-19 cases? Evidence from California skilled nursing facilities. 
JAMDA. 2020: 905-908; Li, Y., Tempkin-Greener, H., Shan, G. and Cai, X. 
COVID-19 infections and deaths among Connecticut nursing home 
residents: facility correlates. JAGS: June 18, 2020.
    \8\ https://ag.ny.gov/sites/default/files/2021-
nursinghomesreport.pdf.

COVID-19 has had a disparate impact on nursing home residents of color. 
Data shows that homes with large populations of Black and Latinx 
residents were disproportionately affected compared to other homes.\9\ 
Congress must ensure that the causes of these disparities are 
investigated and addressed.
---------------------------------------------------------------------------
    \9\ Li, Y., et, al, Racial and Ethnic Disparities in COVID-19 
Infections and Deaths Across U.S. Nursing Homes, Journal of American 
Geriatric Society, 2020 Nov., 68(11):2454-2461; NY Times, https://
www.nytimes.com/article/coronavirus-nursing-homes-racial-
disparity.html?action=click
&module=Well&pgtype=Homepage&section=US%20News.

CMS was slow to require transparency of conditions in nursing homes as 
a result of the pandemic. It was not until May 2020 that CMS required 
all facilities to report data to the CDC about COVID infections, 
deaths, etc., and it failed to require the reporting retroactively. As 
a result, there is little data from the months before May, when tens of 
thousands of residents contracted COVID-19 and died. At the same time, 
CMS waived facility reporting of staffing data to the Payroll-Based 
Journal and delayed reporting assessment data. Complete reporting is 
essential to establish an accurate and complete picture of what 
occurred during this time. It is vital to have this information to 
learn from early failures and help ensure they do not recur. We urge 
Congress to investigate the effect of COVID-19 on nursing home 
residents thoroughly. Any investigation should include recommendations 
to improve care quality and prevent a recurrence of the nursing homes 
---------------------------------------------------------------------------
crisis.

II.  Support the Long-Term Care Workforce Through Minimum Staffing 
Standards, Training, and Increased Wages and Benefits

Staffing

Since CMS began releasing weekly data in May 2020, on average, 19% of 
nursing homes have reported a shortage of nurse aides, while 16% 
reported a shortage in nurses.\10\ Over 554,000 nursing home staff have 
been infected with COVID-19, and at least 1,625 have died.\11\ Many 
workers have resigned due to fear of contracting COVID, family and 
caregiving responsibilities that have increased during the pandemic, or 
frustration due to untenable working conditions. These factors 
exacerbated insufficient staffing levels that pre-dated the pandemic 
and placed workers in impossible situations and residents at risk of 
harm.
---------------------------------------------------------------------------
    \10\ https://data.cms.gov/stories/s/bkwz-xpvg.
    \11\ Id.

The federal government does not require minimum staffing levels, and as 
a result, inadequate staffing has long been a problem in nursing 
facilities. Numerous studies have linked higher staffing levels to 
better care.\12\ CMS's own study on appropriate staffing found a clear 
association between nurse staffing levels and quality care.\13\ 
Insufficient staffing proved deadly during the pandemic, with studies 
showing that facilities with higher staffing levels and ratings fared 
better on controlling COVID-19 spread and resident outcomes than poorly 
staffed homes.\14\
---------------------------------------------------------------------------
    \12\ Castle, N.G., Wagner, L.M., Ferguson, J.C., and Handler, S.M. 
Nursing home deficiency citations for safety. J. Aging and Social 
Policy, 2011; 23 (1):34-57; Castle, N.G. and Anderson, R.A. Caregiver 
staffing in nursing homes and their influence on quality of care. 
Medical Care, 2011:49(6):545-552; Schnelle, J.F., Simmons, S.F., 
Harrington, C., Cadogan, M., Garcia, E., and Bates-Jensen, B. 
Relationship of nursing home staffing to quality of care? Health Serv 
Res., 2004: 39 (2):225-250; Spector, W.D., Limcangco, R., Williams, C., 
Rhodes, W. and Hurd, D. Potentially avoidable hospitalizations for 
elderly long-stay residents in nursing homes. Med Care, 2013: 51 
(8):673-81.
    \13\ Centers for Medicare and Medicaid Services, Abt Associates 
Inc. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes. 
Report to Congress: Phase II Final. Volumes I-III. Baltimore, MD.
    \14\ Li, et. al, 2020, ``COVID-19 Infections and Deaths Among 
Connecticut Nursing Home Resident: Facility Correlates;'' Journal of 
the American Geriatrics Society, Vol. 68, Issue 10, 2153-2162.

Before the pandemic, RN presence was directly related to quality care 
and better outcomes for residents.\15\ It also proved to be predictive 
of outcomes during the pandemic, as homes with total RN staffing levels 
under the recommended minimum standard (.75 hours per resident day) had 
a two times greater probability of having COVID-19 infections.\16\ Yet, 
nursing homes are only required to have an RN present 8 hours daily.
---------------------------------------------------------------------------
    \15\ Dellefield, M.E., Castle, N.G., McGilton, K.S., and Spilsbury, 
K. The relationship between registered nurses and nursing home quality: 
An integrative review (2008-2014). Nurs Econ., 2015; 33(2):95-108, 
116.b
    \16\ Harrington, et. al., 2020, Nursing Staffing and Coronavirus 
Infections in California Nursing Homes; Policy Politics and Nursing 
Practice, 2020, Vol. 21(3) 174-86.
---------------------------------------------------------------------------

Training

Early in the pandemic, the previous administration waived the 
requirement that nurse aides meet training and certification 
requirements \17\ during the Public Health Emergency. CMS claimed that 
the waiver was necessary to address staff shortages. In reality, the 
waiver resulted in Temporary Nurse Aides (TNAs) who were ill-equipped 
to provide necessary care and services to residents and put the workers 
and residents at increased risk of injury. TNAs who had not been 
trained in proper infection control entered a medical setting where 
protecting residents from infectious disease was paramount.
---------------------------------------------------------------------------
    \17\ https://www.cms.gov/files/document/summary-covid-19-emergency-
declaration-waivers.pdf.

To date, this waiver is still in place, and proposals exist at the 
state and federal levels for waving the training and certification 
requirements for these workers permanently. If the pandemic has taught 
---------------------------------------------------------------------------
us anything, it is that more training is needed, not less.

It is also unclear how many untrained and uncertified workers have 
fallen under this waiver and how much training and supervision they 
have had. In fact, it is doubtful whether CMS will be able to determine 
the total number. It would be highly irresponsible to waive these 
requirements without knowing how many staff, and in turn, residents 
will be affected.

The current training requirements for CNAs are inadequate as well. CNAs 
have more contact with residents than any other staff members. However, 
federal training requirements for CNA certification are only 75 hours. 
Increasing acuity and complexity of residents' needs, including higher 
incidences of dementia, warrant a need for increased training 
standards. In its report on the adequacy of the healthcare workforce 
for older Americans (Retooling for an Aging America, 2008), the 
National Academy of Medicine (formerly the Institute of Medicine) 
recommends that ``federal requirements for the minimum training of 
certified nursing assistants (CNAs) and home health aides should be 
raised to at least 120 hours and should include demonstration of 
competence in the care of older adults as a criterion for 
certification'' (Recommendation 5-1).

Increased Wages and Benefits

A report \18\ released by LeadingAge, an organization representing non-
profit nursing homes, documented that almost half of nursing home care 
workers earned less than a living wage, with nearly 57% relying on 
public assistance. One study \19\ documented that nursing homes' 
nursing staff turnover rate was roughly 100% annually, even before the 
pandemic. The LeadingAge report states that increasing wages for 
nursing home workers would reduce this turnover and significantly 
improve residents' health outcomes. Increased wages are necessary to 
attract and retain highly experienced and well-trained workers. On the 
one hand, we cannot call our nursing home workers heroes, while on the 
other, paying them wages that require them to rely on government 
assistance.
---------------------------------------------------------------------------
    \18\ https://leadingage.org/sites/default/files/
Making%20Care%20Work%20Pay%20Report.pdf.
    \19\ Gandhi, A., Yu, G., Grabowski, D. High Nursing Staff Turnover 
in Nursing Homes Offers Important Quality Information, Health Affairs, 
2021, Vol. 40, No, 3.

Further contributing to unsafe conditions for staff and residents, too 
many facilities do not have a qualified infection preventionist to 
support and implement infection prevention and control protocols 
---------------------------------------------------------------------------
necessary to sufficiently address the spread of COVID-19.

Lastly, understaffing is made worse by the failures of CMS to enforce 
adequate staffing levels. A recent report \20\ by the Office of 
Inspector General found that CMS should do more to strengthen oversight 
of nursing home staffing.
---------------------------------------------------------------------------
    \20\ https://oig.hhs.gov/oei/reports/OEI-04-18-00451.pdf.

To better support the facility's staff and attract and retain 
experienced and qualified workers that can increase positive health 
---------------------------------------------------------------------------
outcomes, Congress should urge CMS to:

      End the Trump Administration's waiver of training requirements 
for nurse aides and feeding assistants enacted in March 2020. Require 
temporary nurse aides hired under this waiver to complete full training 
and certification within a designated timeframe to continue working and 
require nursing homes to identify and publicly report numbers of 
Temporary Nurse Aides currently employed.
      Increase initial nurse aide certification training requirements 
from the current 75 hours to adequately prepare frontline aides for the 
complex needs of the people they are hired to assist. Require 
facilities to cover the cost of training.

In addition, Congress should pass legislation that:

      Strengthens the direct care workforce by (a) increasing 
compensation, including hazard pay (b) improving access to affordable 
health insurance, paid family and medical leave, paid sick leave, and 
affordable childcare.
      Requires a minimum staffing standard of at least 4.1 hours per 
resident day.
      Requires 24-hour RN presence in all nursing homes.
      Establishes a robust enforcement mechanism to ensure adequate 
staffing levels.

III.  Require the Rescission of all Waivers of Nursing Home Regulations 
Established Under the Public Health Emergency

In addition to the training and certification waiver, the previous 
administration issued multiple waivers of standards and requirements 
for healthcare providers, including nursing homes, through the use of 
1135 waivers.\21\ These waivers included waiving notice of transfer or 
discharge and facility reporting requirements, including resident 
assessment information and staffing information.
---------------------------------------------------------------------------
    \21\ https://www.cms.gov/files/document/summary-covid-19-emergency-
declaration-waivers.pdf.

The waiver allowing facilities not to report resident assessment 
information and staffing information has been rescinded. However, CMS 
has publicly stated that it will not require facilities to provide the 
staffing information for the period that reporting was waived, even 
though it is readily accessible to nursing homes. When CMS made this 
decision, the period for which the reporting waiver applied had been 
the deadliest for nursing home residents. If we are to understand what 
---------------------------------------------------------------------------
happened during the pandemic, facilities must provide this information.

Waivers must not continue indefinitely without evaluation to assess 
whether they continue to be needed or effective. Many of the waivers 
referred to in this document remove essential resident rights 
articulated in law and regulation.

Congress should urge CMS to:

      Rescind the waivers of nursing facility requirements that permit 
waivers of notice for transfer or discharge due to cohorting and nurse 
aide training.
      Require facilities to report data on staffing from January 1st-
May 2020. All of this data is already in the possession of nursing 
homes and is critical for analyzing what happened during that time and 
what we can do to prevent it in the future.

IV.  Ensure Access to COVID-19 Vaccines for All Residents and Staff Who 
Choose to be Vaccinated

The discovery and release of highly effective and safe COVID-19 
vaccines has offered promise to residents and staff. Since residents 
and staff began receiving vaccinations, COVID-19 case numbers and 
deaths have plummeted. Yet not all residents have equal access to the 
vaccine in nursing homes.

In all states but West Virginia, the CDC partnered with outside 
pharmacies to conduct clinics at nursing homes to have residents and 
staff vaccinated. These pharmacies have adopted a policy of only 
visiting nursing homes three times to vaccinate residents. As a result, 
residents who entered the facility after the second clinic have just 
received one dose of the vaccination. Others who were admitted after 
the third clinic have not received a vaccine at all. In some states, 
plans have not yet been established to ensure continued access to 
vaccines, and in some cases, facilities are requiring residents to 
obtain the vaccination themselves. This policy creates an unacceptable 
burden on residents and families to ensure they become fully 
vaccinated. For many residents, this task will be impossible and will 
result in them going without the protection of a vaccine.

New residents and staff continue entering nursing homes and should be 
offered the vaccine. Currently, there is no policy from the federal 
government setting forth a plan for ensuring these residents can become 
fully vaccinated.

Early reports \22\ stated nursing home staff were refusing vaccination 
at a rate as high as 60%. This high refusal rate has been attributed 
mainly to distrust of the vaccine and a lack of information accessible 
to staff.\23\ CMS and CDC must continue efforts to provide staff with 
information on vaccines that address staff concerns and help increase 
vaccination rates among staff.
---------------------------------------------------------------------------
    \22\ https://www.cnbc.com/2021/02/09/covid-vaccine-60percent-of-
nursing-home-staff-refused-shots-walgreens-exec-says.html.
    \23\ https://www.health.harvard.edu/blog/why-wont-some-health-care-
workers-get-vaccinated-2021021721967.

It is also vitally important for current and future residents and their 
families to have access to information that shows how many residents 
and staff have been vaccinated in each facility. This information will 
be essential for residents to make informed decisions on their care and 
where they want to reside. Although the CDC is releasing total numbers 
of staff and residents who have been vaccinated, it is not at the 
---------------------------------------------------------------------------
facility level.

To ensure all residents and staff have access to the COVID-19 
vaccination, Congress should:

      Require federal, state, and local coordination for ensuring 
ongoing access to vaccines for all residents and staff of long-term 
care facilities.
      Require nursing homes to report the number and percentage of 
their residents and workers who have been vaccinated and disclose that 
information to residents, families, staff, the LTCOP, the State Survey 
Agency, CMS and CDC. Vaccination rates in nursing homes should be 
reported to the CDC and shared publicly on Nursing Home Compare (Care 
Compare).

V.  Ensure Protection from COVID-19 for Residents and Staff by Ensuring 
Ongoing Access to PPE and Testing

As with many health facilities, nursing homes have struggled to obtain 
and maintain adequate supplies of high-quality personal protective 
equipment (PPE). Many nursing homes continue to report less than one-
week supplies of masks, gowns, and gloves.\24\ Additionally, ensuring 
facilities have sufficient access to accurate COVID-19 testing will be 
essential in helping prevent outbreaks. To ensure all facilities have 
adequate PPE and testing, Congress should:
---------------------------------------------------------------------------
    \24\ For instance, for the week ending February 14, 2001, 5% of 
nursing homes reported they had less than a one week supply of N-95 
masks, https://data.cms.gov/stories/s/bkwz-xpvg.

      Establish an effective supply chain for the distribution of PPE 
to long-term care facilities, and ensure funding for sufficient, usable 
PPE to supply nursing home staff, visitors, surveyors, and LTC 
ombudsmen.
      Require all facilities to have a 30-day supply of PPE on hand.
      Provide funding and hold facilities accountable for paying for 
accurate point-of-care testing with rapid turnaround of results for 
staff, residents, and their families who visit.

VI. Fully Restore Visitation in Nursing Homes

On March 13, 2020, CMS issued an order \25\ prohibiting anyone other 
than essential health care workers from entering nursing homes. As a 
result, residents were isolated from their families and subject to 
neglect and harm due to inadequate staffing. As time passed, the harm 
from isolation and neglect began to take a toll on residents' health 
and well-being.\26\ These problems mainly went unseen, as facility 
surveyors, families, and long-term care ombudsmen were restricted from 
entering facilities. Residents could no longer rely on their loved ones 
to draw attention to health declines or inadequate care. As some 
facilities re-opened their doors to visitation, many family members 
discovered their loved ones had experienced a devastating decline, 
including significant weight loss, cognitive decline, emotional 
distress, and extremely poor hygiene.\27\
---------------------------------------------------------------------------
    \25\ CMS, QSO-20-14-NH, updated by QSO-20-39-NH (Sept 17, 2020).
    \26\ https://apnews.com/article/nursing-homes-neglect-death-surge-
3b74a2202140c5a6b5cf05cd
f0ea4f32.
    \27\ https://theconsumervoice.org/uploads/files/issues/
Devasting_Effect_of_Lockdowns_on_Res
idents_of_LTC_Facilities.pdf.

On March 10, 2021, CMS issued new visitation guidance \28\ that relaxed 
some of the visitation restrictions. While a step in the right 
direction, the guidance does not go far enough, however, to protect 
residents from the effects of isolation and neglect. The guidance 
language allows facilities significant discretion when determining the 
length and frequency of visits, including for compassionate care. CMS 
must require facilities to permit visits based on the needs of each 
resident and enforce those requirements.
---------------------------------------------------------------------------
    \28\ CMS, QSO=20-39-NH.

Further, residents continue to need access to telecommunications 
devices and Internet services in order to communicate with family and 
friends who are unable to visit in person. Such access is necessary for 
supporting many residents who suffer from isolation. Despite efforts to 
increase access during the pandemic, many facilities do not have 
devices that can be used by residents who do not have their own, and 
there are facilities that refuse to allow a resident to connect their 
---------------------------------------------------------------------------
personal device to the facility's Internet connection.

To help protect residents, Congress should:

      Allow every resident to designate an essential support person 
(ESP). The ESP must be allowed unrestricted access to residents to 
provide physical and emotional support and assistance in meeting 
residents' needs. ESPs should be treated as employees of the facility 
for infection control purposes, including routine COVID-19 testing and 
the wearing of PPE (cost to be borne by the facility).
      Urge CMS to modify its visitation guidance to require facilities 
to permit visits based on the needs of each resident and, until full 
visitation rights are restored, ensure that visits are no less than one 
hour weekly.
      Require CMS to enforce visitation guidance.
      Pass legislation that provides access to telecommunications 
devices and the Internet for all residents.

VII.  Reinstate Annual Recertification and Complaint Surveys and 
Strengthen Regulations and Enforcement

Recertification and Complaint Surveys

At the same time visitation bans were instituted, the previous 
administration suspended surveys and enforcement except in very limited 
situations. CMS directed State Survey Agencies to prioritize the most 
egregious complaints (triaged as immediate jeopardy) and implemented a 
new type of survey focused on infection prevention and control 
requirements,\29\ to the exclusion of all other issues. As a result, 
state survey agencies did not conduct complaint investigations (except 
for immediate jeopardy) or annual surveys for months. Complaints of 
rights violations, neglect, eviction, and similar serious issues were 
ignored to the residents' great detriment.
---------------------------------------------------------------------------
    \29\ CMS, QSO-20-20-All.

While CMS issued guidance in September 2020 to reinstate survey 
activities, not all states have. As of the date of this hearing, 
California, Ohio, and Tennessee, for example, still have not begun 
completing annual recertification surveys. California is still only 
---------------------------------------------------------------------------
investigating IJ-level complaints.

Congress should urge CMS to ensure that all states are conducting 
annual recertification surveys and investigating all complaints.

Regulations

In 2017 CMS issued final federal rules for nursing homes that rolled 
back the ban on pre-dispute arbitration and in 2019 issued proposed 
rules to further roll back the revised nursing home rules published in 
2016. These proposed rules would provide fewer protections for 
residents and less accountability for nursing facilities by, among 
other things, weakening standards relating to infection prevention, use 
of antipsychotic medications, and responding to resident and family 
grievances.

Congress should:

      Urge CMS to rescind its 2019 proposed rules to ensure that 
nursing home residents are not stripped of these necessary protections.
      Pass legislation banning forced arbitration agreements in 
nursing homes.
      Urge CMS to reinstate the regulation banning nursing home 
arbitration agreements.

Enforcement

Prior to the pandemic, insufficient enforcement of regulations long 
plagued nursing home care. Deficiencies were under-cited and often did 
not \30\ identify serious problems. Enforcement actions are also not 
sufficiently meaningful to bring about lasting change, as evidenced by 
a 2019 \31\ OIG report that found that 31 percent of nursing homes had 
a deficiency (violation) cited at least five times during 2013-2017, 
and \32\ a study which determined that 42 percent of deficiencies were 
given for chronic or repeated deficiencies in a 3-year period.
---------------------------------------------------------------------------
    \30\ Office of the Inspector General (OIG). States continued to 
fall short in meeting required timeframes for investigating nursing 
home complaints: 2016-2018. Data Brief. Washington, DC: OIG OEI-01-19-
00421. September 2020.
    \31\ Office of the Inspector General (OIG). Trends in deficiencies 
at nursing homes show that improvements are needed to ensure the health 
and safety of residents. HHS Data Brief. April 2019. 09-18-02010.
    \32\ A Long Term Care Community Coalition. Issue Alert. Chronic 
deficiencies in care: The persistence of recurring failures to meet 
minimum safety and dignity standards in U.S. nursing homes. LTCCC, 
February 2017. http://nursinghome411.org/nursing-homes-with-chronic-
deficiencies/.

Enforcement was further weakened by actions taken under the previous 
administration. In 2017, CMS revised its enforcement policy to change 
the default method of assessing civil money penalties for past non-
compliance from the imposition of ``per-day'' fines to ``per-instance'' 
fines. This change removes any incentive for facilities to identify and 
correct non-compliance as early as possible, resulting in residents 
subjected to potentially harmful non-compliance for an extended period. 
We believe this revision was made in violation of proper administrative 
---------------------------------------------------------------------------
procedures.

These failures of enforcement certainly contributed to the crisis in 
nursing homes during the pandemic. Repeated and long-standing 
violations are the result of facilities facing little pecuniary 
punishment. As noted above, 8 out of 10 facilities had infection 
control violations before the pandemic, with half of those having 
repeated problems. Until CMS adopts a rigorous and consistent 
enforcement strategy, the issues that led to the devastation in nursing 
homes will continue.

Congress should:

      Require CMS to ensure that comprehensive and complaint surveys 
have been fully restarted in all states.
      Direct CMS to withdraw the proposed rules on nursing facility 
Requirements of Participation published Federal Register, Vol. 84, No. 
138, July 18, 2019, 34737.
      Strengthen federal and state enforcement by requiring pre-
established per-day penalties and utilizing denials of payment for 
resident admissions for non-compliance with specific requirements, such 
as staffing, transfer/discharge, life safety, emergency preparedness, 
and infection control.
      Instruct CMS to rescind the Trump Administration directive, 
``Revision of Civil Money Penalty (CMP) Policies and CMP Analytic 
Tool'' (S&C 17-37-NH), which instructed State Survey Agency Directors 
and CMS Regional Offices that ``per-instance'' CMPs would be imposed 
for past non-compliance, conflicting with the enforcement provisions in 
the Social Security Act that provide for the imposition of CMPS for 
``each day of non-compliance.''

VIII.  Require Transparency and Accountability Around Nursing Home 
Ownership and Finances

For years, the nursing home industry has been plagued by poor care 
brought on by the purchase of homes by corporations and Private Equity 
Investment (PE) firms with little or no experience in healthcare or 
with a long history of providing substandard care. A study released in 
February 2021 estimated that PE ownership of a nursing home increases 
the mortality of Medicare residents by 10%, results in declines in many 
measures of well-being for residents and increases taxpayer spending 
per resident by 11%.\33\ A recent report in the Washington Post 
revealed that even during the pandemic, investment groups with a long 
track record of owning homes that provide poor quality care were 
allowed to buy over 20 homes and that care suffered.\34\
---------------------------------------------------------------------------
    \33\ https://www.nber.org/system/files/working_papers/w28474/
w28474.pdf.
    \34\ https://www.washingtonpost.com/local/portopiccolo-nursing-
homes-maryland/2020/12/21
/a1ffb2a6-292b-11eb-9b14-ad872157ebc9_story.html.

Corporate and PE firms have slashed resources, including cutting staff 
and supplies.\35\ It is common practice for them to pay related third 
parties, such as vendors, management companies, and others, for 
services as a means of funneling money to themselves.\36\ Yet, there is 
no system to audit the use of federal funds and determine whether they 
go to profits or resident care.
---------------------------------------------------------------------------
    \35\ Harrington, C., Olney, B., Carrillo, H., Kang, T. Nurse 
staffing and deficiencies in the largest for-profit chains and chains 
owned by private equity companies. Health Serv Res., 2012; 47(1 pt. 
I):106-128.
    \36\ Harrington, C., Ross, L., Kang, T. Hidden ownership, hidden 
profits, and poor quality of nursing home care: A case study. 
International Journal of Health Services, 2015;45 (4): 779-800.

To improve the quality of care in nursing homes and to ensure the 
---------------------------------------------------------------------------
appropriate use of taxpayer money, Congress should pass legislation:

      Mandating audits to determine how facilities spend taxpayer 
money.
      Setting limits on administrative costs and profits for all 
payors.
      Requiring CMS to establish federal regulations to specify the 
minimum criteria for purchasing or managing any nursing home.

IX. Address Disparities in Care for Racial and Ethnic Minorities

All residents are entitled to quality care and services, access to 
justice, and protection from discrimination. Black and Latinx nursing 
home residents have been disproportionately affected by COVID-19.\37\ 
Research has shown the disparities in care experienced by individuals 
based on race, ethnicity, and socioeconomic status have become 
pronounced during the COVID pandemic.\38\ This research points to long-
standing racial inequities that pre-date COVID-19. Due to 
discriminatory lending policies, housing segregation, greater reliance 
on Medicaid, and inequitable health-
care access, marginalized populations are more likely to reside in 
racially and ethnically identifiable nursing homes that provide poorer 
care. Data gathering practices and targeted interventions must be 
developed to ensure that residents' care needs are met.
---------------------------------------------------------------------------
    \37\ Li, Y., Cen, X., Cai, X., and Temkin-Greener, H. Racial and 
ethnic disparities in COVID-19 infections and deaths across U.S. 
Nursing Homes. JAGS, 2020:1-8 DPO:10:1111/jgs.16847.
    \38\ Gebeloff, R., Ivory, D., Richtel, M., Smith M, Yourish K., 
Dance, S., Fortier, J., Yu, E., and Parker, M. (2020). Striking racial 
divide: How COVID-19 has hit nursing homes. The New York Times, May 21, 
https://www.nytimes.com/article/coronavirus-nursing-homes-
racialdisparity.
html?action=click&module=Well&pgtype=Homepage&section=US%20News.

CMS policies make addressing disparities in care difficult. Although 
CMS collects data on race and ethnicity, it does not release this data 
to the public, which has created a gap in knowledge regarding how 
minority groups are treated in nursing homes. However, COVID-19 has 
laid bare that residents of color receive inferior quality of care when 
---------------------------------------------------------------------------
compared with others.

We urge Congress to:

      Require CMS to collect and report nursing home resident 
demographic data specific to race and ethnicity, source of payment, and 
ownership.
      Require CMS to require facilities to report racial demographic 
data as part of the weekly data facilities report to the CDC.
      Make CMS race and ethnicity data publicly available dating back 
to the beginning of the pandemic. Policymakers, government agencies, 
advocates, providers, and researchers need this information to identify 
disparities in care and to develop enforceable public policies to 
ensure equitable care for all residents.
      Investigate and address the disparities in care and access to 
services for racial and ethnic minorities, including disparate care and 
outcomes in nursing homes under common ownership and operation, 
Medicare and Medicaid policies that allow or promote discrimination 
based source of payment, and other factors that result in disparate 
placement in poor-performing, racially identifiable nursing homes, such 
as hospital discharges.

X.  Expand Choice Through Expansion of Medicaid Home and Community 
Based Services
For many older adults with limited income and resources, needing 
assistance with activities of daily living means going to a nursing 
home. However, during the pandemic, many older adults chose to remain 
home without sufficient supports to avoid the risk of being infected 
with COVID-19 in a nursing home. While the implementation of Medicaid 
waivers has improved access to home and community-based services (HCBS) 
for these individuals, HCBS is not a required benefit under Medicaid, 
and for those states where waivers exist, there often are limits on 
coverage, limited availability of service providers and affordable 
housing, and long waiting lists. The devastating effect of COVID-19 on 
people living in congregate settings has only highlighted the need to 
make HCBS a required benefit. Increased access to HCBS would likely 
have saved lives during the pandemic.

To allow individuals who could successfully remain in or transition 
back to their homes or community-based settings instead of entering or 
staying in a nursing home, we urge Congress to:

      Make HCBS a required benefit under Medicaid and allow coverage 
of housing-related services and retroactive coverage for HCBS services.
      Permanently reauthorize the Money Follows the Person program, 
which has helped older adults and persons with disabilities transition 
from institutions into the community.
      Direct resources for more low-income housing and residential 
care.

The pandemic's tragic impact on residents and staff of nursing home 
residents was years in the making. Many of the recommendations in this 
statement have been made by advocates for years, in part because it was 
foreseeable that a virus like COVID-19 would devastate nursing homes. 
We call on Congress to act now and take decisive steps to not only 
prevent the next crisis, but to increases the quality of care in 
nursing homes for current and future generations.

            Sincerely,

            The National Consumer Voice for Quality Long-Term Care
            Community Legal Services of Philadelphia
            Michigan Elder Justice Initiative

                                 ______
                                 
  Statement Submitted by Mary Nichols, Texas Caregivers for Compromise
March 13, 2021 was one year since families were declared non-essential 
and prevented from freely visiting loved ones in long-term care 
facilities. CMS issued new guidance on March 10, 2021 that allows 
expanded visitation but not only are most nursing homes still not in 
compliance, but the guidelines do not apply to assisted living 
facilities, group homes, intermediate care facilities and group homes 
that do not received Medicaid and Medicare funding so those facilities 
are still largely autonomous when it comes to regulating visitation. 
Families must learn complex guidelines in order to argue to be admitted 
to facilities or obtain assistance from an ombudsmen. This is 
disproportionately skewed against lower income populations who work 
multiple jobs and lack the luxury of being full-time advocates, 
populations with language barriers, and those populations without 
higher levels of education who struggle to decipher technical legalese 
and analyze these complicated regulations against the restrictions 
being given to them by their loved one's facility.

The severe weight loss, rapid cognitive decline, and extreme 
despondency in residents from COVID-19 protocols continue to result in 
loss of both life and quality of life. The mental health crisis taking 
place among residents, families, and long-term care staff members 
cannot be overstated as the intense pressures on people affected by 
guideline enforcement increase daily. For a full year, residents have 
felt abandoned and forgotten, life-long spouses have been separated, 
adult children with cognitive disorders have not seen a parent or 
sibling, dementia and Alzheimer's residents have lost memory of their 
loved ones, people have died alone, and families have lost what time 
remained with their loved ones who passed away in this last year.

CMS GUIDANCE IS MISUSED. Guidance put in place by CMS on September 17, 
2020 and March 20, 2021 is widely misunderstood by facilities and the 
visitation provisions within them have neither been acknowledged nor 
implemented in a great many facilities in a majority of states. 
Commonly, facilities point to CMS guidelines as the reason they cannot 
allow any form of visitation. This is false. Meanwhile, recourse by 
state health authorities is absent and there is no reason to anticipate 
that facilities who ignore current visitation standards will follow 
future or amended rules.

ESSENTIAL CAREGIVERS ARE NOT A PERMANENT SOLUTION. Many states are 
adopting essential caregiver provisions that allow one or two family 
members access to care for a resident for a few minutes or an hour or 
two a week. Essential caregivers are a temporary solution for 
visitation as they only allow a small increment of restoration of 
resident rights. As we see many states beginning to adopt programs 
similar to the Texas and Florida programs, our concern is that the 
perception by our lawmakers will be that this is an acceptable 
permanent alternative to visitation in long-term care facilities when, 
instead, it is an emergency answer to be used as a last resort.

ADA VIOLATIONS. Current prohibition of visitation has resulted in 
widespread and readily accepted violation of the Americans with 
Disabilities Act.

        UNEQUAL FAMILY ACCESS. Those residents who are cognizantly 
        healthy enough to use telephones, virtual visits and talk 
        through closed windows have far more access to family than 
        those bed-bound, deaf, blind, and intellectually disabled 
        residents as well as residents with advanced dementia and 
        Alzheimer's who are incapable of seeing virtual technology as 
        anything other than white noise, are bed-bound and unable to go 
        to a window, or become agitated and harm themselves when they 
        don't understand why a relative remains on the other side of 
        glass. Blind adults who depend on tactile communication are 
        eliminated from these visits, deaf adults are restricted by 
        small screens and windows are often not even wheelchair 
        accessible.

        UNEQUAL PROTECTION FROM ABUSE AND NEGLECT. Intellectually 
        disabled adults and residents with dementia or Alzheimer's have 
        unequal protection from abuse and neglect as those residents 
        who are able to push a call-button or phone a relative. Outside 
        visitors, clergy, family, powers of attorney, hospice workers, 
        ombudsmen, and legal guardians are the extra eyes that assess a 
        resident's environment and welfare and affect change should 
        there be an issue or deficiency. The absence of those eyes 
        removes that protection from people incapable of calling for a 
        tray because the lunch cart missed their room, asking for a 
        shower, reporting a bedsore, or complaining about soiled 
        clothing. They have also lost those eyes that are familiar 
        enough to notice the subtle differences in the health or 
        behavior of the resident that staff members--frequently 
        temporary substitutes--might miss. This was one of the major 
        purposes of the 1987 Nursing Home Reform Act.

RESULTS OF FACILITY AUTONOMY. Facilities have had twelve months of 
authority over decisions related to and rights of residents in long-
term care facilities. While they must have ability to make 
administrative choices that best suit their facility's needs, these 
choices have crossed over into decisions that:

      Deny rights of residents guaranteed in state and federal law;
      Make care decisions without resident and/or family input;
      Circumvent guidelines put in place by Texas Health and Human 
Services;
      Circumvent Centers for Medicaid and Medicare Services 
guidelines; and
      Ignore recommendations of the CDC regarding discontinuation of 
transmission based precautions for patients recovering from COVID-19

Facilities will not release this authority without argument and 
resistance as the involvement of family members is often no longer 
welcome but considered interference. While CMS guidelines do not apply 
to all facilities, the ones that they do apply to often either do not 
know the guidelines, do not understand the guidelines, or simply choose 
not to follow the guidelines. The issues rising from those facilities 
are many and egregious:

      Refusing essential caregivers in states that allow them;
      Not allowing hospice workers for a year;
      Denying end-of-life visits;
      Denying compassionate care visits;
      Not following CDC recommendations re: discontinuation of 
transmission-based precautions when a resident has recovered from 
COVID-19 and isolating asymptomatic residents 24 to 35 days instead of 
10;
      Denying closed window visits;
      Not allowing a resident to use his/her own property;
      Making residents remain in their room, refusing communal dining, 
and not allowing outdoor recreation, walks, or fresh air;
      Prohibiting residents from opening or receiving mail;
      Requiring a family to use the hospice company of the facility's 
choice;
      Refusing indoor plexiglass visitation;
      Making resident care decisions without consulting legal 
guardians, family, or Medical POAs;
      Not allowing resident to participate in religious activity;
      Not holding required care plan meetings with family members;
      Denying resident a right to refuse a treatment; and
      Denying ability to report abuse or neglect by refusing to allow 
use of facility telephones

ONE YEAR IS THE REMAINDER OF A LIFETIME. The life expectancy of a 
resident once he or she moves into long-term care is six months to two 
years depending on which statistics you believe, the health of the 
resident and the type of care required. The restrictions will have been 
in place a year on March 13, 2021. That is the remainder of many 
people's lifetimes.

POST-VACCINE VISITATION. New CMS guidance discriminates residents based 
on whether they choose or decline the vaccine. There is much vaccine 
reluctance at this time among many minority populations and this 
regulation makes visitation rights disproportionately skewed against 
those minorities. Residents in a county with 10% or more positivity who 
have not received the vaccine are denied visitation. Not only is this a 
disguised mandate of an emergency use vaccine but it makes a resident's 
rights dependent on the choices of everyone else in the county to mask, 
social distance, practice infection control, or receive the vaccine. 
Nobody's statutory and federal rights should be dependent on the choice 
somebody else makes.

DANGEROUS PRECEDENT. COVID-19 was an unprecedented crisis in our 
country. But the unprecedented has now become precedented and we have 
set a dangerous one. Imagine a war, emergency, crisis, or pandemic in 
the future that disproportionately affects children under a certain age 
or people of a certain genetic background or race. Would this country 
stand for stripping them of their rights for their own good for over a 
year? As ridiculous as that sounds, could we have imagined eighteen 
months ago that residents in long-term care facilities would be 
restricted from visitation and all those rights in the 1987 Nursing 
Home Reform Act for a year? It's time that we agree that in the United 
States of America the rights of no population should ever again end the 
moment a pandemic begins.

                                 ______
                                 
                  Oregon Health and Science University

                     3181 S.W. Sam Jackson Park Rd.

                           Portland, OR 97239

                              www.ohsu.edu

Statement of Dr. Emily Morgan, Assistant Professor of Internal Medicine 
and Geriatrics, Oregon Health and Science University; Medical Director, 
                  Mirabella Skilled and Long Term Care

Chairman Wyden, Ranking Member Crapo, and Members of the Committee:

We are pleased to submit this statement for the record to offer 
feedback on the Department of Health and Human Services Centers for 
Medicare & Medicaid Services' (CMS) memorandum on Nursing Home 
Visitation during the COVID-19 Public Health Emergency published on 
March 10, 2021. We greatly appreciate the continued efforts of CMS to 
ensure the health and safety of our vulnerable nursing home population 
and we wholeheartedly agree with CMS' commitment to ending the social 
isolation faced by many nursing home residents during this pandemic. 
However, we feel it is important that we voice our concern regarding 
how these changes are implemented, with the shared goals of reducing 
the burden of isolation and keeping our most vulnerable population 
protected.

We are concerned that the emphasis placed on allowing indoor visitation 
``at all times and for all residents'' will unduly place residents and 
facility staff at increased risk without additional limitations in 
place. We ask that CMS consider adding an exception that clearly states 
that indoor visitation will not be permitted when a facility cannot 
safely ensure appropriate physical distancing and oversight during 
visitation. We are concerned that facilities overwhelmed with visitors 
will not have the available staffing needed to ensure safety protocols 
are being appropriately followed, while at the same time delivering 
adequate care to residents.

We would also like CMS to consider changing the use of 10% county test 
positivity rate as an exception scenario for allowing un-restricted 
indoor visitation. Test positivity is a crude measure of transmission 
risk, but most would consider a rate of >10% as indicative of 
widespread and un-controlled transmission in the community. Happily, 
many counties in Oregon as well as other states have not seen 
positivity rates this high even during the peak of the pandemic. We 
believe that protecting the safety of residents and staff would best be 
served by continued limits on visitation unless the local risk of 
disease is low, for example, <5%. Also, since test positivity rates may 
be highly dependent on access to testing, consideration should be given 
to including other metrics, such as the rate of new cases/per 100, 000 
population over the preceding 14 days (incidence rate) to determine 
restrictions on visitation. (See https://coronavirus.oregon.gov/Pages/
living-with-covid-19.aspx#current
risklevelbycountyma for an example of how incidence rates and test 
positivity may be combined as indicators of COVID-19 spread in the 
community). In our opinion, restriction of indoor visitation should be 
allowed unless local disease transmission has been minimized.

Lastly, we are concerned about the CDC's Updated Healthcare Infection 
Prevention and Control Recommendations in Response to COVID-19 
Vaccination, published March 10, 2021 which states ``quarantine is no 
longer recommended for residents who are being admitted to a post-acute 
care facility if they are fully vaccinated and have not had prolonged 
close contact with someone with SARS-coV-2 infection in the prior 14 
days. The potential for recent SARS-CoV-2 exposure of patients who are 
being newly admitted to nursing homes cannot always be accurately 
determined, whether they are being admitted from an acute care hospital 
or the community. Risk of exposure may be highly variable depending on 
community rates and/or the quality of infection control practices at 
the referring care facility. In addition, we know that vaccination is 
not 100% effective in preventing SARS-CoV-2 infections, and the level 
of protection provided against emerging virulent and highly 
communicable genetic variants of concern is still uncertain. Although 
the risk of COVID-19 disease among fully vaccinated patients may be 
relatively low, the consequences of transmission within a nursing home 
can be devastating. Quarantine of newly admitted nursing home residents 
remains an important tool in outbreak prevention. While quarantine is 
isolating, perhaps the best way to address this would be to recommend 
quarantine for 7 days accompanied by testing to shorten the quarantine 
period while maintaining this important safeguard.

We are thankful for the continued efforts of CMS and the CDC to 
prioritize the health and wellness of our nursing home residents and 
staff. It is with much excitement that we look forward to increased 
visitation and decreased isolation for our residents that have suffered 
so much in this last year. We appreciate the Committee's interest in 
this issue and CMS' willingness to consider the feedback we offer here 
and move to implement safe visitation and transitions of care policies 
that continue to offer the highest degree of protection to our nursing 
home communities.

With Many Kind Regards,

Emily Morgan, M.D.

Cc: Liz Richter, Acting Administrator, Centers for Medicare and 
Medicaid Services

                                 ______
                                 
                   Letter Submitted by Carolyn Piper
Thank you for the opportunity to add my statement to the record of this 
hearing. I am a 70 year old daughter, living in NV, of parents residing 
in long-term care in PA. Unfortunately they are in two separate 
``facilities'' in a continuing care conglomerate, since they need 
different levels of care. My mother requires skilled care, on the 
second floor of her building. My father requires assisted living care, 
residing on the ground floor of the same building. Thus their dwellings 
are under separate licenses, making my father the dreaded ``Visitor'' 
this past year.

From the time of my mother's stroke almost 4 years ago, I was traveling 
to PA every month for the first year, then every 6-8 weeks after that 
until Feb 2020. My mother has no language and no mobility, totally 
helpless and dependent on others. Every single communication is done by 
the same hand wave, and we spent hours trying to determine what she 
wanted or needed. The frequency of my visits was to ensure that my 
parents' needs were being met, to participate in planning meetings, and 
to advocate for unmet needs. I was also able to provide extra direct 
care and stimulation to my mother for participation in some activities 
(she declined everything that staff offered), general stimulation and 
conversation, long walks outside in her wheelchair (which staff never 
had time to do and which was the only recreation that was meaningful to 
her in any way) and eating assistance because we discovered through 
diligent trial and error what she liked to eat and how it could be 
prepared on her tray to help her to be the most independent in feeding 
herself as possible. I was her voice, because she no longer had one. 
Prior to COVID, I worried about the long hours that she was languishing 
alone in her bed for 20 hours every day. But I knew that between my 
visits, my 2 brothers and sister, and my nephew were visiting sometimes 
multiple times a week. They provided all of these same things.

And then with no warning, no one was allowed back in. My mother, who 
does not read a newspaper, and does not watch TV, and whose brain is 
severely damaged from her massive stroke, only knew that no one was 
coming anymore to take her outside, or wheelchair walks through the 
building, or fix her meal tray, or brush her hair, or brush her teeth, 
or clean her dirty face, or wipe the scum and smell from between her 
clenched fingers, or make sure staff saw the crust and redness on her 
inner elbow or under her breast or on her elbow, and then treated it 
properly. She surely must have felt abandoned, alone, depressed, 
despondent. She had no concept of virus, or mitigation, or pandemic. 
Not even my father was allowed back in. And what we thought would be a 
two week separation turned into a year. My brother and nephew got a 
couple ``window visits,'' but my hard of hearing mother could not hear 
them through the glass door and masks. She did not comprehend why they 
did not come in. Then there were Facetime calls, which she did not even 
understand before her stroke, and with no communication on her part, 
all we could do was to ``eyeball'' her and try to explain in words she 
probably did not remotely comprehend why we were no longer coming. My 
sister had one compassionate visit with her in her room during the 
year, but could not go at lunch to provide feeding help, could not walk 
her anywhere (not allowed out of the room), could not go on the weekend 
(not enough staff) and was allowed two visits and done. Just an 
arbitrary rule from what we could understand. I was ``not allowed'' in 
for a year, because the PA governor issued a prolonged 14 quarantine 
stipulation for out of state travelers into PA, and my finances did not 
allow for two weeks in PA and then two visits with my parents.

In addition to my own personal story, I am a member of a national 
Facebook group called Caregivers for Compromise- Because Isolation 
Kills too. There are over 14,000 members. The PA chapter that I belong 
to has over 600 members. So, over the last several months, I have read 
hundreds of tragic stories about long term care residents and their 
families suffering through this often total and prolonged isolation, as 
they lived and too often died alone.

Here is what I have learned this past year, and what I would like to 
share about my perspective on this tragedy.

I shudder to think what would have happened to my mother without family 
there to support her and encourage her and advocate for her and 
sometimes even fight for her 4 years ago when she first entered the 
nursing home. Her care was standard, but I know without any doubt that 
her family was the critical element to her living. We supplemented 
direct care and our presence was her medicine. We saw things that staff 
missed and interpreted her hand waves because in their busy every day 
work life, there was not time to spend hours to figure out what she 
wanted or needed. We helped to relieve her anxiety because she no 
longer spoke but we knew she was aware and afraid and helpless. We were 
there to help her match cards, and copy letters, and try to speak, and 
exercise her arms and legs. Having lost all mobility on her own, we 
walked her miles in her wheelchair. We were her lifeline and her 
connection to the world outside of her 12 by 12 room.

How many thousands of new residents have entered long-term care 
facilities this past year with no one to support them or encourage them 
or advocate for them, or report neglect that they saw? How many were 
unnecessarily medicated because they seem depressed, or anxious, or 
starting having ``behaviors''? How much was all of this due singularly 
to isolation? How many died with no one by their side, and no good 
byes? Have you seen all the pictures that have been posted of 
accelerated decline? The ``unintended consequence'' to the lockdown? Or 
as residents would say, the lock-up? Residents suffered and families 
suffered and there will never be closure for them.

We learned that facilities earned ``rewards'' from the federal 
government for reducing COVID cases. On the surface, that mitigation 
success seems to be a very good thing. But how did this very monetary 
award incentivize keeping families out? How were those funds used to 
enhance ongoing and meaningful connections with

In May 2020, the Centers for Medicare and Medicaid Services (CMS) 
issued some visitation guidelines but I don't think families ever 
grasped very well that these existed and how to get them enforced. By 
the time of the new guidelines in Sept. 2020, we were more educated and 
sharing information with each other. Still, the guidelines were vague 
and up for much interpretation.

Just to summarize the great disparity, and with all other things being 
equal related to outbreak status and county positivity rate:

      Some facilities arranged compassionate care visits. Others 
absolutely did not.
      Some facilities eventually worked with families to a compromise. 
Others stood with a firm no.
      Some facilities told families, well if we let you in, we will 
have to let others in. So they still said no. And yet every single 
resident should have been entitled to a compassionate visit after 10 
months of being confined to their room and many times not even 
understanding why their family had abandoned them to be left alone.
      Some allowed daily up to two hours. Even twice daily. Some 
allowed twice a week, because they said CMS said that these visits 
should ``not be routine.''
      Some allowed these visits at meal times (so the family member 
could actually support a need.) Others said absolutely not at meal time 
(even in a resident's private room) because the resident would have 
their mask off. But really, families could wear masks while they helped 
with a meal, just like staff could.
      Some required the family find their own COVID test. Others (a 
very few) would provide the test on site prior to the visit. Where were 
all the tests that the Governors had received? Wasn't finding ways to 
safely reunite families a priority?
      Some required testing every three days, some twice a week, even 
when staff were tested weekly or monthly. That was a monumental 
challenge and hardship for family members who were trying to stretch 
the truth so they could schedule free tests at CVS. Or it's out of 
pocket at a private lab, up to $125.
      Some continued Compassionate visits with county positivity over 
10%. Others shut down all but perhaps a single end of life visit when 
positivity exceeded 10%. Some even restricted all Compassionate visits 
for up to 4 weeks based on this positivity rate, when there had been 
only one or two (``reported'') asymptomatic positive non-resident cases 
and no one in the building was in isolation. The PA Division of Nursing 
Facilities told me, and the CMS document from Sept 17 stated, that CC 
visits are to supersede county positivity. My correspondence to a CMS 
Triage email verified this. But who are we to argue with facilities 
when we have no backing because there was just enough vagueness in the 
guidance that they could "twist it," or perhaps merely misunderstand 
it?

What was most frustrating to us as family members, was that all these 
facilities say they are following ``The Guidelines.'' The Sept. CMS 
guidelines were vague, ambiguous, and contained too many gaps. And 
there has been no one for us to ask, unless a formal complaint is made. 
Family members have feared further reprisals for complaining to their 
State Nursing Division more than anything. Many are even reluctant to 
call the State Ombudsman office for compassionate visitation help, out 
of fear of what the facility will do going forward in disguised 
retaliation.

Now CMS has new ``guidance,'' issued in March, and residents and 
families have been deluded to think this will answer our prayers and 
our grass roots advocacy goals. Families in many locations are still 
begging for Compassionate visits. But what does a Compassionate Visit 
mean? In recent interviews Evan Shulman, the Director of the CMS 
Division of Nursing Home Quality and Safety, has said that they cannot 
possibly define all examples of a Compassionate visit. So after a year 
of lock-up, some facilities around the country are still denying these, 
because ``mom has not declined enough.'' ``Dad's problems are not acute 
enough.'' ``Your sister is not depressed enough.'' What? A year without 
a family visit is not in and of itself reason enough to allow a 
compassionate visit? Or families plead for an end of life visit, which 
is sometimes denied until the very end. ``Grandma is not close enough 
to death to allow you in.'' Have you seen any broad news coverage about 
people who try to visit a dying loved one in a nursing home and the 
police are called to escort them out, as their loved one is actively 
dying? Probably not. It has been hard to get media attention to this 
tragedy. But it is happening. And we see it up close and personal on 
our Facebook page.

Mr. Shulman also says these compassionate visits should not ``be 
routine.'' What does ``Not Routine'' mean? Some families are allowed a 
15 minute visit once per week. Weekdays only. No children. Sometimes 
only one visitor, maximum is two. CMS says that they ``understand.'' I 
do not believe they do. They say these guidelines are what facilities 
``should follow'' since they are not federal ``regulations.'' In PA, 
where my parents live, the Governor and Acting Health Secretary say 
facilities ``should'' follow these new guidelines, and that they 
``encourage'' it. So, please help me to understand. If states say that 
facilities ``should'' follow the guidelines that CMS says that they 
``should'' follow, then how is any of this enforceable? Some state 
Nursing Division agencies have been very helpful when people do take 
the leap to make a complaint. Others side with any arbitrary 
restrictions that the facility imposes. Some State Long Term Care 
Ombudsman offices have been very helpful when people do take the leap 
to make a request for advocacy. Others say there is nothing they can 
do, placing them precisely in concert with any arbitrary restrictions 
that the facility imposes. And from the family vantage point, CMS and 
State regulators are doing nothing to ensure this is being understood 
and universally implemented in facilities across our nation. That has 
left us fighting individual battles all over the country, because they 
tell us they will ``investigate'' our ``complaints'' but they have not 
been proactive to clarify guidance or issue clear expectations that it 
is being adhered to.

Mr. Shulman says these compassionate visits should be ``person-
centered.'' Facilities do not understand what this means on a normal 
day. So, what does person-
centered even mean when every right is being taken from individuals 
residing in long-term care facilities? And what gives the facility 
administrator the right to measure and to determine the value and worth 
and necessity of a resident being ``allowed'' to see a family member?

This is an injustice to loved ones who are seniors, adults and children 
who are living in long term care. Their rights have been stripped, not 
for 2 weeks which we could have probably lived with, but for a year. 
How have we allowed this to happen? Where is the outrage? This is a 
humanitarian crisis going on for thousands across our own country. 
Right here, in the USA. People have stated this week that the disparity 
of the NCAA men's and women's locker rooms and food is ``disgusting.'' 
The NCAA has ``apologized'' to the women. Where is the outcry over long 
term care residents locked up for over a year? Who has apologized to 
them? Who has given them an ounce of attention for months? Who has 
cared about them? Why are people in isolation no less a disgraceful 
situation than the fact that locker rooms have different equipment? 
Where are our priorities?

This can never happen again, and we apparently need Regulations to make 
sure that it does not happen again. I beg you to respond to this crisis 
by having a Committee that will legislate humanity and compassion for 
all of these residents, current and future. Because it is clear that 
compassion and humanity are optional in our current world. On any given 
day, I could be the next person locked up in long term care without 
access to my family. Any one of you could be as well. Or your spouse or 
parent or your child.

Believe me, I do not for one minute dismiss the severity of this 
pandemic, nor do I have any disregard for the tremendous loss of life 
it has caused. But with no one seeming to be paying any attention for 
the last year, there has been an equally devastating loss of life, or 
devastating loss of physical and cognitive capacity to those have 
suffered alone on the inside. They have lost their will, and their 
spirit, and their mental health, and their emotional health as well. 
And yet facilities would deny that those individuals ``qualify'' for a 
compassionate visit from a loved one? And CMS would condone the 
inconsistencies in the implementation of their so-called guidelines 
through their own very stance of inaction to ensure this is properly 
interpreted and happening? CMS ``shoulds'' are inadequate. Our State-
based ``shoulds'' are meaningless. We need federal laws that will 
mandate that Essential Caregivers are allowed for long term care 
residents, even in a pandemic, and even when other regular visitation 
might have to be limited for safety reasons. And I would propose that 
we need another federal mandate that says that the Resident Rights, as 
guaranteed and protected by the federal Nursing Home Reform Act 
established in 1987, can never again be violated to the extent that we 
have just witnessed. Even in a pandemic, residents should be entitled 
to the ``quality of care that will result in their achieving or 
maintaining their `highest practicable' physical, mental and 
psychosocial well-being.'' Any thing less is unjust, immoral, and 
inhumane. Just as this very tragedy has been for a full year.

Respectfully submitted

Carolyn Piper
Daughter of parents residing in Long Term Care
Member of National and PA chapters of Caregivers for Compromise--
Because Isolation Kills Too

                                 ______
                                 
                              Premier Inc.

                     444 N. Capitol Street NW #625

                          Washington, DC 20001

The Premier healthcare alliance appreciates the opportunity to submit a 
statement for the record on the Senate Finance Committee hearing titled 
``A National Tragedy: COVID-19 in the Nation's Nursing Homes.'' We 
applaud the leadership of Chairman Wyden, Ranking Member Crapo and 
members of the Committee for examining the factors that contributed to 
the nursing home response during the pandemic and assessing necessary 
improvements going forward.

Premier Inc. is a leading healthcare improvement company, uniting an 
alliance of more than 4,100 U.S. hospitals and health systems and 
approximately 200,000 non-acute providers, including 28,000 nursing 
homes around the country, to transform healthcare. With integrated data 
and analytics, collaboratives, supply chain solutions, and consulting 
and other services, Premier enables better care and outcomes at a lower 
cost.

It is indisputable that COVID-19 has had devastating consequences for 
the nation's nursing homes. Deaths among senior-care center staff and 
residents appear to represent at least 25 percent of the overall count 
of more than 500,000 U.S. fatalities related to COVID-19, as compiled 
by the Centers for Medicare & Medicaid Services (CMS).\1\ Since the 
COVID-19 outbreak, a key focus area of Premier has been ensuring 
nursing homes, which were wholly unprepared to deal with the magnitude 
of the pandemic, have personal protective equipment (PPE), supplies and 
equipment at their sites so they can continue to deliver high-quality 
care to residents.
---------------------------------------------------------------------------
    \1\ https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-
xpvg/.

Through two comprehensive surveys and dozens of individual 
conversations to understand the needs of senior living providers during 
the pandemic, Premier developed solutions and recommendations that we 
shared with the Administration. In addition to supply chain issues, 
which require critical thought moving forward, we believe additional 
funding is necessary to implement technological supports in nursing 
homes. Specifically, infrastructure is needed to help infection 
preventionists and clinical pharmacists at facilities detect, manage, 
control and report infection-related conditions related to COVID-19 and 
beyond. We urge Congress to address known supply chain and surveillance 
vulnerabilities for this unique population in the next COVID-19 
package.

               CONGRESSIONAL ACTION IS NEEDED TO ADDRESS 
                      SUPPLY CHAIN VULNERABILITIES

As a supply chain leader, Premier has been at the forefront of COVID-19 
response efforts and has been working around the clock to ensure a 
consistent supply of medical supplies for nursing homes, including PPE. 
Premier has been actively engaged with the Administration and federal 
agencies to track developments and offer guidance, providing real-time 
data on ordering patterns, current consumption rates and future demand 
forecasts in order to inform our government's understanding of the 
current state and potential future vulnerabilities.

Premier conducted several surveys \2\ to better understand the needs of 
nearly 2,500 skilled nursing and assisted living facilities during the 
pandemic response and found that:
---------------------------------------------------------------------------
    \2\ https://www.premierinc.com/newsroom/premier-in-the-news/senior-
living-facilities-lack-supply-of-protective-gear-survey-finds and 
https://www.premierinc.com/newsroom/press-releases/as-covid-19-pushes-
hospital-patients-to-post-acute-care-settings-supply-and-resource-
needs-grow-per-premier-inc-survey.

      About 43 percent of senior living facilities did not have a 
consistent ordering history for PPE at the outset of the pandemic, 
effectively leaving them without a legitimate channel for purchasing 
supplies that may be necessary to protect workers and elderly 
residents. Of senior living providers that did have a consistent 
purchasing history of PPE products, 87 percent were not receiving the 
full quantity of products ordered at the outset of the COVID-19 
pandemic.
      By early April, 24 percent of senior living facilities did not 
have N95 masks on hand, and the majority had fewer than 2 weeks' supply 
of surgical masks, isolation gowns and face shields.
      Additional products in high demand for senior living facilities 
and short supply from manufacturers and distributors included 
thermometers, exam gloves, shoe covers, bouffant caps, alcohol pads, 
disinfecting products, hand sanitizer, and disposable paper items. This 
demonstrated the unique needs of nursing homes from other healthcare 
settings.
      These supply chain challenges have left nursing homes 
vulnerable, as 70 percent reported they are not fully prepared to treat 
an increasing number of COVID-19 cases as the virus surges.

Given these findings and barriers for nursing homes to obtain PPE 
through traditional distribution channels, Premier created an e-
commerce platform, Stockd, to ensure nursing homes were able to access 
critical medical supplies during the pandemic in a timely manner. Built 
by providers for providers, Stockd helps solve the issue of gray market 
sellers and illicit marketeers that were rampant during the pandemic 
through:

      Robust security settings to prevent the selling of ``gray 
market'' goods, or those that are sold outside of the brand owner's 
approved distribution channels.
      Stringent vetting policies that safeguard buyers and ensure that 
they're purchasing from verified manufacturers and distributors, not 
third-party sellers who may price gouge or make suspect product claims 
based on market demand.

Stockd will continue to be a critical resource for nursing homes moving 
forward as they adjust to the new normal and continue to obtain PPE to 
protect both healthcare workers and nursing home residents.

To strengthen the supply chain to address future global pandemics, 
Premier has robust recommendations on how the existing private sector 
supply chain can be further enabled and augmented. Premier's guiding 
principles include:

      Augment the existing private sector supply chain to better 
respond to global pandemics through diversification and transparency. 
The private sector supply chain is highly functioning and should be 
further enabled, not disrupted.
      Develop a cohesive and holistic national strategy for addressing 
global pandemics and stabilizing the US supply chain to respond to 
surge demand for critical medical supplies and drugs.
      Identify critical medical supplies and drugs needed to treat a 
global pandemic and associated comorbidities. This identification 
should occur via a public-
private advisory council that includes representatives from 
manufacturers, group purchasing organizations (GPOs), distributors, 
physicians, pharmacists, laboratorians, nursing homes, and others. This 
list must be dynamic and regularly updated as technology advances, best 
practices are identified, and the practice of medicine evolves.
      Create upstream visibility into the supply chain to understand 
sources of raw materials and manufacturing facilities. This information 
is critical to assess vulnerabilities and prioritize what critical 
medical supplies and drugs should be focused on initially to assure 
adequate diversification of the supply chain.
      Design stockpiles to create coordination rather than competition 
between state, local and national stockpiles.
      Invest in a robust, real time HIT infrastructure that will 
provide an on-call, nimble data collection infrastructure that the 
nation can call upon in any future major crises. Rather than standing 
up an inadequate and duplicative system as we experienced during the 
pandemic, the nation needs a system that can track critical product 
availability--from the raw materials, to manufacturer, to distribution, 
to hospital inventory. This system would exist behind the scenes and be 
ready to be ``turned on'' in a moment's notice. This information would 
inform dynamic and appropriate product allocation and distribution 
strategies, minimize hoarding, and enable powerful and accurate 
prediction, enabling the nation to manage supplies during the crisis.
      Leverage supply and demand data from GPOs, who serve as neutral, 
vendor-agnostic, and value-orientated entities to drive transparency in 
the supply chain and forecast demand needs.
      Advance payment and delivery system reforms that hold providers, 
including nursing home providers, accountable for the health of a 
population, budgets and transparent outcomes. This will incent 
improving the health of a population, which will both improve patients' 
comorbidities and attention to care management for sick patients. 
Acting within a budget helps reduce long-term financial pressure from 
rising healthcare costs.
      Leverage technology to implement comprehensive infection 
prevention and antimicrobial stewardship programs in nursing homes to 
provide meaningful assistance with infection control.

Premier urges Congress to ensure that nursing homes are represented in 
the development of a cohesive and holistic national strategy for 
addressing global pandemics. Furthermore, a customized stockpile for 
nursing homes should be created with appropriate supplies, drugs and 
other needs.

               Funding for Infection Prevention Clinical 
                   Surveillance Will Improve Outcomes

COVID-19 has brought to the forefront the specific challenges nursing 
homes face in containing the spread of infectious disease. The virus 
has accelerated at nursing homes because residents are generally 
vulnerable to its complications and more susceptible in the contained 
space of the facilities. While data about infections in nursing homes 
is limited, the CDC notes that, even prior to the pandemic, a 
staggering 1 to 3 million serious infections occur every year in these 
facilities and as many as 380,000 people die of the infections in 
nursing homes every year.\3\
---------------------------------------------------------------------------
    \3\ https://www.cdc.gov/longtermcare/
index.html#::text=1%20to%203%20million%20serious,
infections%20in%20LTCFs%20every%20year. 

Infection prevention oversight and training at nursing homes is a 
challenge in and of itself with limited staffing and several layers of 
reporting requirements. This challenge is compounded by limited 
electronic health record (EHR) functionality at the sites with only an 
estimated 66 percent of skilled nursing facilities currently using an 
EHR.\4\ Data regarding use of EHRs in other segments of nursing homes 
such as long-term care facilities and independent living are considered 
to be much lower. The use of paper records in these care settings 
inhibit swift data collection and proactive tracking and trending to 
identify potential infections before they become rampant in the 
congregate setting. Surveillance, tracking, documenting and reporting 
of infections is not only necessary for COVID-19 but could be used to 
better position nursing homes for future outbreaks and other indicators 
that would result in improved quality of care.
---------------------------------------------------------------------------
    \4\ https://www.healthit.gov/sites/default/files/page/2018-11/
Electronic-Health-Record-Adoption-and-Interoperability-among-U.S.-
Skilled-Nursing-Facilities-and-Home-Health-Agencies-in-2017.pdf.

Nursing homes now have multiple, expanded layers of infection 
prevention requirements and face unique challenges with oversight and 
---------------------------------------------------------------------------
training without electronic surveillance capabilities

      CMS now requires facilities to:
          Establish and maintain an infection prevention 
and control program (IPCP) that includes, at a minimum, a system for 
preventing, identifying, reporting, investigating and controlling 
infections and communicable diseases for all residents, staff, 
volunteers, visitors, and other individuals providing services under a 
contractual arrangement.
          Report on at least a weekly basis confirmed and 
suspected COVID-19 cases, or face penalties.

      This is on top of infection reporting requirements that vary by 
state and can often require using phone, fax or mail, as well as 
reporting requirements within facilities' own organizations.

      Infection prevention oversight and training is challenging, 
which is compounded by limited technology nursing homes due to:
          High resident-to-staff ratios which are 
associated with infection spreads;
          A lack of on-site specialty services, such as 
pharmacists for antimicrobial stewardship;
          Functions that are often outsourced to outside 
agencies, which then hold the data;
          Surveillance, tracking and reporting processes 
lack automation for everyday risks such as multidrug resistant organism 
(MDRO) and for outbreaks like COVID-19.

Clinical surveillance solutions should be implemented to improve 
quality and decrease costs

      Clinical analytics technologies are currently widely leveraged 
in hospitals and acute settings, including 46 Veterans Affairs 
hospitals, to detect patient care issues through surveillance, 
interventions and reporting capabilities that are needed to support 
antimicrobial stewardship programs. These systems utilize data from 
EHRs and have significantly helped clinicians and pharmacists in acute 
settings identify overuse of antibiotics and drug-bug mismatches, 
reduce time-to-appropriate therapy and enhance therapy for difficult-
to-treat pathogens. Those health systems already utilizing clinical 
surveillance technology were well positioned to respond to COVID-19 
before the pandemic hit. This technology is ready to optimize for 
nursing homes, delivering similar results to those below.

          Three Veterans Health Administration medical 
centers (VAMCs) saved $2.3 million in just two years by changing the 
way they administer antibiotics, using a clinical surveillance system 
to ensure appropriate and safe use of antibiotics for the men and women 
who have served our country.
          Hartford Healthcare in Hartford, CT, streamlined 
its workflow for identifying high-risk patients, conducting patient 
reviews, completing documentation, and reporting infection data to 
CDC's National Healthcare Safety Network (NHSN) across its six 
hospitals. This saved 10 hours per week per infection preventionist, 
allowing them to spend more time with clinical staff educating and 
observing infection prevention processes.
          Ellis Medicine, in Schenectady, NY, saved more 
than $122,000 in a year by implementing clinical surveillance to meet 
both New York State Department of Health and Joint Commission 
requirements for stewardship to easily identify bug-drug mismatches, 
duplication of therapy, and opportunities for de-escalation or 
discontinuation of therapy.

Incentivizing this technology would help nursing home preparedness 
beyond the COVID-19 public health emergency

      We urge Congress to designate funds specifically to ensure 
nursing homes can implement electronic clinical surveillance technology 
(ECST) that will provide meaningful assistance with infection control.

          For the purposes of the public health emergency 
and for 180 days after, Congress should incentivize facilities that 
already have EHRs to adopt and integrate ECST.
          For those facilities that do not have existing 
EHRs, Congress should designate additional resources to implement that 
foundational technology and to also adopt and integrate ECST.

Unfortunately, clinical analytics technologies are currently not widely 
used in nursing homes. Nursing homes should have the same access to 
tools that will help them combat infection spread during any future 
outbreaks of COVID-19 and during their day-to-day operations, but 
unfortunately funding remains a significant barrier. Nursing homes are 
already challenged with meeting their more visible needs, such as 
testing and securing adequate PPE levels at their sites, but a 
comprehensive approach is additionally needed to ensure data collection 
is efficient, non-duplicative and being analyzed in ways that are 
helpful for facilities. Furthermore, it is critical that lessons 
learned from meaningful use are applied forward as we develop cohesive 
solutions to address the lack of EHRs and clinical surveillance 
technology in nursing homes and create appropriate incentives for 
adoption.

Premier urges Congress to designate funds to incentivize nursing homes 
to implement EHRs and electronic clinical surveillance technology that 
will provide meaningful assistance with infection control.

                               CONCLUSION

In closing, the Premier healthcare alliance appreciates the opportunity 
to submit a statement for the record on the Senate Finance Committee 
hearing to examine the COVID-19 nursing home crisis. As an established 
leader in the healthcare supply chain and healthcare data analytics, 
Premier is available as a resource and looks forward to working with 
Congress as it considers policy options to continue to address these 
very important issues. If you have any questions regarding our comments 
or need more information, please contact Soumi Saha, Vice President of 
Advocacy, at [email protected] or 732-266-5472.

                                 ______
                                 
                   Statement Submitted by Beth Rister
    Hello, I am Beth Rister from Southern Illinois. I am an educator, 
currently serving as Regional Superintendent of nine counties. I 
consider myself a very hard worker. While serving in a full- time job, 
I also look after my mother who has Parkinson's, and is starting down 
the road of dementia. I will not bore you with all the details, but 
just know through a very trying year, my mother had to move from an 
assisted living to a nursing home. I stood at the window of the nursing 
home from May to October every evening. I tried to comfort my mother by 
talking to her on a cell phone through a glass. The facility would not 
allow the screen to be opened, which would have allowed fresh air in, 
thus helping the ventilation and the communication. I would leave after 
working all day, and standing an hour or two, crying my eyes out. It 
was so hard on me, as well as on her. I could see things that needed to 
be done in her room. I could see personal care that needed to be done 
for her well-being. One very important thing was walking. She had 
broken her hip, and she needed to walk more than 10 minutes a day. As 
an essential part of her care, I would have gone in daily and walked 
her, to keep her strength up. She was losing the ability to walk right 
in front of my eyes. She is unable to brush her teeth appropriately due 
to shaking. I again, would brush her teeth daily for her. I would help 
her with her supper. Many times the tray was just set down in front of 
her, and the aide (sometimes a housekeeper) would turn around to walk 
out of the room. I would be knocking on the window, asking them to open 
her Jell-O, her crackers, cut her meat, etc. If I had not been at the 
window, she would have been unable to eat some of the items on her 
tray. I know at lunch and breakfast, she was not properly cared for, 
because I was unable to be at the window. There are many situations, 
where essential caregivers from family are needed. The long term care 
facilities are short staffed, many not properly trained. Many 
residents, like my mother need so much care, and during COVID was 
unable to get this care. The facility does not always have the capacity 
to care for the residents like they deserve to be taken care of. These 
are former hardworking members of our nation, law abiding citizens, 
taxpayers, being held hostage in their last months of their life. It is 
a crying shame for anyone to be treated like this, and kept from family 
members who are willing to help them.

    I ended up taking my mother out of the facility on October 11th. I 
was not about to stand outside all winter to see about my mother. She 
and my father lived very conservatively, and was able to build a small 
nest egg. They never made big money, but just new how to manage. The 
nursing home cost was $5,000 a month, I am now paying over $11,000 a 
month for 24 hour care at home. We will be running out of money very 
soon. I want to see a solution to this problem, before my mother has to 
return to such a facility. I want to be able to go to her room, help 
her with essential care. I shouldn't have to watch a video, take a 
quiz, etc. to do so. Some of the facilities are trying to make it so 
hard, people will give up. This is America, we deserve better treatment 
than this! My mother was a former nursing home administrator. She ran a 
fine long term care facility. The residents were like family to all the 
staff. Boy, how times have changed!

    I am asking you, no begging you to pass a bill, like SB 2160 to 
allow one or two essential family members to enter a facility, go to 
their loved one's room, to take care of the essential needs of their 
loved one. There are many physical needs, as well as the social 
emotional needs. They need to be shown love, not isolation.

    Thank you for your time and consideration. I could care less if I 
inherit a dime. I will spend ever last penny my parents saved over 
their lifetime to care for my mother. My father passed in 2019, before 
the pandemic. He was fortunate enough to stay home, with just 6 months 
of caregivers. The money is running out very quickly. Please help.

                                 ______
                                 
                  Statement Submitted by Nora Toscano
I am 60 years old, and live in Tucson, AZ. I graduated from the 
University of Connecticut in 1983 with a dual degree in Electrical 
Engineering and Computer Science. I have been married for 36 years. My 
husband is also a University of Connecticut graduate with an Electrical 
Engineering degree. We have no children. I retired from Raytheon 
Missile Systems as a Senior Manager Systems Engineer. Prior to COVID, I 
volunteered 1 day a week at a local hospital. Recently I started 
volunteering at a local AZ COVID vaccine site.

My Mom, Aneita Babicz, passed away at the age of 82 from COVID on July 
7, 2020 after living in a Memory Care facility since Jan 2020.

My Mom's Story:

My Mom was diagnosed with Dementia and Early Onset Alzheimer's in late 
Nov 2019 from the University of Arizona Alzheimer's Institute. I 
learned dementia patients need structure, activities, and 
socialization; two things my husband and I struggled to provide her 
during several months that she lived with us. She became a resident of 
Catalina Springs Memory Care in Oro Valley, AZ in Jan 2020. With the 
environment at the Memory Care Facility, she really improved and loved 
being with ``new best friends.'' She enjoyed many daily activities and 
structure. I would visit her at least 3 times a week just to make sure 
she was doing well and was happy. It was a great place for her.

On March 13th the Memory Care facility started implementing 
restrictions due to COVID, which included no longer allowing visitors. 
The staff started wearing face masks at this point.

Beginning in May residents were also given masks and were asked to wear 
them when they were in the common area. Residents were also told to sit 
apart from each other, and they were no longer allowed to hug each 
other anymore. My Mom struggled because she needed a hug every day. But 
at the same time my Mom really tried to do as she was told.

Around the end of May new mandates were imposed that all residents must 
eat all meals in their own rooms by themselves (Mom had a single room). 
Dementia residents need to be around each other and because of this 
mandate my Mom started withdrawing and no longer ate her meals like 
before. I would stop by during lunch to watch her through her closed 
window, and she would just push food around on her plate. It was hard 
to get her to eat. She really needed her friends to eat with her. 
Initially I would call her on her own phone and talk to her during 
lunch to convince her to eat. She was able to see me standing at her 
window. However, being in isolation and her seeing me at her window 
would only upset her more, so eventually I had to stop calling her. I 
would still visit at her window but I would not let he know I was 
watching her during lunch. It was so sad to watch.

The situation got worse for my Mom when a revised mandate from the AZ 
Governor was issued for all Nursing Homes and Long-Term Facilities to 
mandate all residents to stay in their rooms, alone, all day long. This 
meant my Mom had to sit in her one chair, without a TV, or radio, and 
her eyesight was bad so she couldn't read. She had no contact with 
other residents all day long. This isolation does not work for dementia 
patients, and it would not even work for individuals without dementia; 
it is essentially solitary confinement. At times my Mom would call me 
from her personal phone to complain about being mistreated. Other times 
she yelled at me, her anxiety was getting worse. She did not want to be 
in ``jail.'' She was done with the facility and wanted to go home. It 
was really hard on me too since there was not much I could do to help. 
We considered moving her to another facility but the state was not 
releasing COVID test results data for Long Term Facilities so we were 
unsure if we would be placing her at a greater risk elsewhere.

Being alone also caused my Mom's dementia to quickly worsen. Her 
anxiety issues and her perception of reality was declining. She feared 
that a big bad man was coming into her room at night to get her. I 
later found out the staff would periodically peak in on residents at 
night, but in the dark and with the staff wearing masks, it scared my 
Mom. Therefore, my Mom was not getting much sleep at night either.

I could not reach any staff in the Memory Care Facility to help with 
this matter. I kept hearing they were short staffed. It was impossible 
for me to reach anyone to ask for help for my Mom or find out what was 
really going on. There was no feedback for me, nor was there anyone for 
me to talk to about how she was doing and how we could help her. It was 
just that she was in a facility with a big wall around it and I could 
not get any information personally or by phone. Communication was nil.

The facility was also not telling me much about whether a resident had 
COVID or not. I heard from a friend who was an employee that a new 
resident was moved into the facility with COVID, but they were 
isolating that person in their room. However, the same staff that took 
care of the COVID patient cared for everyone else in the facility. It 
seems to me that things could have been handled better. I did not 
expect the facility to admit COVID positive patients and risk my Mom's 
health.

At the time COVID testing and PPE were hard to come by in AZ.

The facility did test residents for COVID, but between the months of 
March and July my Mom was only tested twice for COVID, the second time 
being the week before she was sent to the hospital where she was 
diagnosed as COVID positive. I never did hear the results of the second 
test performed by the Memory Care Facility.

On Monday June 29, 2020, my Mom, a Type II Diabetic, was found slumped 
over in her room on her chair unresponsive. They called for an 
ambulance which identified her with low blood sugar (12) and took her 
to the local hospital. There she was diagnosed as COVID positive and 
they put her in the COVID ICU ward. She was still asymptotic and doing 
well for a couple days, but by Wed July 1st she took a turn for the 
worse. The doctor put her on Remdesivir and Dexamethasone but she 
showed no signs of improving. Since she also had heart valve issues she 
did not want to be put on a ventilator. I was able to meet her doctor 
in person at the Hospital on Thursday July 2nd outside the ICU ward to 
get a briefing on expectations, etc., but to my surprise I was not able 
to go inside the ICU ward due to lack of proper PPE. Therefore, I could 
not say good-by to my Mom.

The hospital told me I would get daily updates by phone, but that did 
not always happen, they were so swamped taking care of patients it was 
hard for them to find the time to talk to family members on the phone. 
By Sat July 4th I heard from the doctor that my Mom was not getting any 
better and there was nothing more they could do for her. I was told I 
needed to think about Hospice care. On Monday July 6th they transferred 
her to a nearby Hospice called Casa de la Luz. I had selected them 
because the assured me that they had PPE I could use to visit her once 
a day.

Once at the Hospice I found out I could not go inside because they did 
not have proper PPE to give me, despite what they told me in advance. I 
was able to see her outside her first story open window, but at this 
point she just lay in bed with her eyes closed. It was Tucson in July 
and temperatures reached over 105. I saw several other families 
gathered outside the windows of their dying COVID loved ones. It was 
all very sad. However, I don't think my Mom knew I was there. I was 
able to play her a CD of her Dad singing Irish music through her window 
which I think she could hear. She passed later that night.

The last time I saw my Mom in person was March 10th. She passed, alone, 
in a strange room on July 7, 2020.

Issues:

While at the Memory Care Facility there were several issues that I 
believe were Systemic Failures:

      Lack of availability of COVID testing and how it took way too 
long for the PCR tests to be reported back to the individuals tested 
(7-10 days).
      Lack of sufficient available PPE for me to visit my dying Mother 
in the hospital and in Hospice prior to her passing.
      Inadequate staffing at the Memory Care Facility to identify that 
my Mom was sick with COVID prior to sending her to the hospital, or to 
identify someone else in the Long Term Facility was asymptotic with 
COVID before this person was able to pass COVID on to other residents, 
including my Mom.

Conclusion:

I believe there was a Systemic Failure caused by a lack of leadership 
from the Federal government which flowed down to the state governments, 
and in the end hurt most Long-Term Memory Care and Dementia Facilities 
and their residents. If only there was cooperation and synergy among 
the states and the Federal government, many lives could have been 
saved.

Dementia patients cannot be treated like those in Nursing Homes and 
other non-dementia patients.

PPE availability was not well regulated nor distributed, therefore 
every Long-Term Facility, Hospital, and Hospice seem to be on their own 
to find available PPE and were competing with each other for whatever 
limited PPE was available.

COVID testing was also scarce and the few local places that were 
performing PCR tests at the time were so overloaded with requests that 
the test results would take 7 to 10 days, or longer. Waiting for 
results for that long seem unproductive, since a lot could happen in 10 
days with this rapid spread of this virus, plus the individual being 
tested could get worse within these critical 10 days. In addition, 
asymptomatic individuals ended up spreading the virus to those more 
susceptible to COVID.

Inadequate staffing for Long Term Facilities resulted in patients who 
were sick with COVID symptoms being overlooked until they got to the 
point where they had to be hospitalized. In addition, results from 
COVID testing on asymptomatic individuals came too late to quarantine 
those asymptomatic from the rest of the residents in the facility 
before they spread it to others.

Recommendation:

If the message from the Federal Government would have been consistent 
and more proactive, I believe many more innocent people may have 
survived 2020. Better management of PPE and COVID testing expectations, 
along with separate guidance for Dementia patients vs. Nursing Homes 
from the Federal Government would also have saved lives. It is a shame 
that mandates like wearing masks became so political, and still is. 
Individuals no longer act for the best of the national, but for 
themselves.

The year 2020 was a difficult time for many Americans. Any help you can 
bring to protect the welfare of our elderly, would be greatly 
appreciated.

                                 ______
                                 
         Statement Submitted by Michael R. Wasserman, M.D., CMD
To paraphrase the historian Toynbee, ``a society's quality and 
durability can best be measured by the respect and care given its older 
adults.'' I am both appreciative and disappointed by today's testimony 
by John E. Dicken, ``COVID-19 in Nursing Homes: HHS Has Taken Steps in 
Response to Pandemic, but Several GAO Recommendations Have Not Been 
Implemented.'' With the devastation that nursing home residents and 
staff have experienced over the past year, the gravity of this issue 
and the urgency needed to address underlying faults in the long term 
care system should be apparent. The bottom line is that there is still 
much that needs to be done to protect the most vulnerable members of 
our society.

One year ago I said the coronavirus was ``the greatest threat to 
nursing home residents that we have seen,''\1\ and that nursing homes 
could become our ``killing fields.''\2\ My experience as a clinical and 
quality expert, in addition to having been the CEO of a large nursing 
home chain gave me a unique perspective into COVID-19, and how existing 
structural weaknesses in the nursing home industry would have tragic 
outcomes. It is unfortunate, but my predictions have come to pass, with 
devastating consequences in nursing homes across the country.
---------------------------------------------------------------------------
    \1\ https://www.nbcnews.com/health/health-news/coronavirus-nursing-
homes-greatest-threat-years-here-s-what-they-n1153181.
    \2\ https://www.cbsnews.com/news/coronavirus-nursing-home-death/.

I am board certified and fellowship trained in geriatric medicine. In 
1989, I opened Kaiser-Permanente's first outpatient geriatric consult 
clinic and in 1994 founded Kaiser's second Continuing Care Department 
in the country. I subsequently went on to become the president and 
chief medical officer of GeriMed of America, a geriatrics medical 
management company, before founding Senior Care of Colorado, which 
became the largest primary care geriatrics private practice in the 
country at the time. I was the Executive Director, Care Continuum, 
overseeing the nursing home arm of Medicare's California QIN-QIO. I 
then became the chief medical officer overseeing the largest nursing 
home chain in California, becoming their CEO for fourteen months before 
---------------------------------------------------------------------------
resigning in November of 2018.

From the moment that I heard about the outbreak at Life Care Center of 
Kirkland, my entire body of experiences informed me as to what was 
coming. I have been working ever since attempting to educate policy 
makers and government officials in order that they might have a better 
understanding of the nursing home industry in order to better protect 
residents and staff. My first articles published in March were focused 
on the need for effective infection prevention, including a focus on 
the front line staff.\3\, \4\
---------------------------------------------------------------------------
    \3\ https://www.mcknights.com/blogs/a-mantra-in-wake-of-
coronavirus-stay-home-and-save-a-life/.
    \4\ https://www.linkedin.com/in/mike-wasserman-8535676/detail/
recent-activity/posts/.

On February 29th, with the outbreak of COVID-19 in a Washington state 
nursing home, the experts in geriatrics and long term care medicine 
knew what was coming. Many of us did everything in our power to sound 
the alarm. Unfortunately, our voices were not heard in a timely 
fashion. We must all live with the dire consequences. We must also 
recognize and thank the incredible people who serve on the front lines 
in nursing homes. They are incredibly caring and compassionate human 
beings, many of whom don't even make a living wage. Media accounts of 
nursing home care all too often ignore their efforts. Too many have now 
given their lives unnecessarily due to the lack of immediate action to 
this pandemic on the part of the federal government, the state, the 
---------------------------------------------------------------------------
counties and the nursing home industry.

COVID-19 ultimately made its way into most nursing homes. There are 
those who use this fact to create a false narrative that there was 
little that could have been done to have significantly reduced the 
devastating impact of this virus on nursing home residents. Nothing 
could be further from the truth. There was a lot that could have been 
done, and we must honor those who have died by taking action to 
reimagine the nursing home industry. My comments will focus first on 
the pandemic response, as there are specific operational elements that 
should be reviewed and can not be ignored. However, these elements are 
only the beginning, and we have been fortunate to already have the 
beginning of a roadmap for the future put forth by the Coronavirus 
Commission on Safety and Quality in Nursing Homes, which I suggest 
should immediately be reconstituted in the form of a Federal Advisory 
Committee. Many of their recommendations should immediately be acted 
on. The dissenting opinion must not be ignored and needs additional 
work in order to achieve consensus. Those who have given their lives 
deserve this level of attention.

In April of 2020, CALTCM published our ``Long Term Care Quadruple Aim 
for COVID-19 Response,''\5\ the pillars of which have withstood the 
test of time and continue to reflect the key elements necessary to 
combat this deadly virus. CALTCM's Quadruple Aim was developed and 
shared with the California Department of Public Health (CDPH) in March, 
and with CMS in April, and was posted on the CALTCM website on April 
17th. It starts with the need for every nursing home to have an 
abundance of Personal Protective Equipment (PPE). Pandemic supply chain 
dynamics made procuring PPE challenging. The state, counties and 
facilities did not have the wherewithal to transcend this challenge in 
order to obtain PPE for every nursing home. As we know, the federal 
government, through the DPA process, had the ability to surmount this 
challenge and should have immediately done so. Additionally, and 
pertinent to reimagining nursing homes, real estate owners and REIT's 
behind the nursing home industry had the ability to leverage their 
assets to acquire PPE, and generally chose not to intervene. As a 
clinician, I don't care who takes responsibility for the acquisition of 
PPE, it just has to happen. Without PPE, COVID-19 can't be stopped. 
While everyone was complaining about the lack of PPE and the inability 
to acquire it, nursing home residents were infected with the virus and 
died. Even today, according to Mr. Dicken's testimony, ten percent of 
nursing homes still struggle to have adequate PPE. This is 
unacceptable. The single most important intervention (prior to the 
availability of a vaccine) in nursing homes, assisted living facilities 
and group homes is an abundance of PPE. In the future, the government 
and the industry must transcend all obstacles and assure that a lack of 
PPE will never again get in the way of protecting vulnerable older 
adults.
---------------------------------------------------------------------------
    \5\ https://www.caltcm.org/assets/
CALTCM%20COVID19%20QUADRUPLE%20AIM%20FI
NAL.pdf.

The second element of the Quadruple Aim is readily available testing. 
Nursing home staff were the main vector for transmission of the virus. 
CALTCM convened a group of experts who developed recommendations 
related to testing.\6\ Testing of all staff was critical to protecting 
both the residents and the staff themselves. Telling nursing homes to 
come up with their own plans for testing was never the answer. The 
federal government should have used its clout and resources to assure 
that testing was performed and that labs prioritized the processing of 
the tests. The nursing home industry should similarly have supported 
testing by actions rather than words. In the coming months and years, 
we will hear many stories of where this did not happen due to 
fundamental weaknesses in both our government and the industry. What is 
truly unfortunate is that even today our country's testing capabilities 
are not state of the art.
---------------------------------------------------------------------------
    \6\ Wasserman M, Ouslander JG, Lam A, et al. Editorial: Diagnostic 
Testing for SARS-Coronavirus-2 in the Nursing Facility: Recommendations 
of a Delphi Panel of Long-Term Care Clinicians. J Nutr Health Aging. 
2020;24(6):538-443. doi:10.1007/s12603-020-1401-9.

Stellar infection prevention is the third element of the Quadruple Aim. 
The Centers for Disease Control and Prevention, and countless 
Departments of Public Health across the country worked tirelessly to 
provide nursing facilities with infection control training. 
Unfortunately, that approach was always going to be insufficient if the 
nursing home industry wasn't fully on board with embracing the role of 
infection preventionist's to their fullest extent. The worst kept 
secret in the nursing home industry is the fact that the infection 
preventionist (IP) is not allotted the time necessary to do an 
effective job. Furthermore, the key reason for requiring a full-time IP 
is the need to literally ``hot-wire'' the nursing home chain of 
command. Most nursing home administrators are focused on their census, 
and also lack expertise in clinical areas. One of the immediate 
solutions to the COVID-19 pandemic that we developed was the concept of 
a virtual centralized support and guidance center that could provide 
expertise to individual nursing homes on a daily basis. Such a support 
and guidance center could have been used to support COVID-19 positive 
nursing homes. CALTCM published a white paper on this in April,\7\ and 
a paper on the concept in July.\8\ We also shared this concept with 
CDPH and CMS in March and April, respectively. The need to specifically 
engage the IP was one element of our recommended approach. In fact, on 
March 13th, CALTCM proposed that every nursing home in California be 
mandated to require their designated infection preventionist (IP) be 
full-time. It took nearly 3 months for the CDPH to make this 
recommendation part of every nursing home's mitigation plan. In the 
fall, Governor Newsom signed AB 2644, making it a requirement that 
every nursing home in California have a full-time infection 
preventionist. The recommendation requiring the need for full-time 
infection preventionists was also made to CMS in April, countering 
previously watered down guidance in the nursing home regulations. We 
must do everything possible to support the role of the facility IP. 
Doing this early in the pandemic would have improved the success of the 
federal and state governmental efforts. Effectively impacting the 
operations of nursing homes requires a paradigm shift with a focus on 
the improved delivery of clinical care. The requirement of a full-time 
IP is a necessary, but not sufficient, step in the right direction.
---------------------------------------------------------------------------
    \7\ https://www.caltcm.org/assets/
WHITE%20PAPER%20A%20Plan%20to%20Protect%20Our%
20Nursing%20Home%20Residents%20.pdf.
    \8\ Wasserman M, Wolk AJ, Lam A. Jour Nursing Home Res, 2020;6:24-
29. An Aspirational Approach to Nursing Home Operations During the 
COVID-19 Pandemic. http://dx.doi.org/10.14283/jnhrs.2020.6, https://
www.jnursinghomeresearch.com/2263-an-aspirational-approach-to-nursing-
home-operations-during-the-covid-19-pandemic.html.

The fourth and final element of the Quadruple Aim is that nursing homes 
must operate in their emergency preparedness mode. This is essentially 
a proxy for excellent leadership and management. If COVID-19 has shone 
a light on one thing, it's the inherent weaknesses in the management 
structure of nursing homes. Nursing homes are complex small businesses, 
delivering care to frail older adults with multiple chronic illnesses. 
They are literally mini-hospitals, but with far fewer resources. 
Nursing home administrators are not prepared to run a hospital, and 
should not be expected to have the skills necessary to manage a 
facility during a pandemic. More importantly, running a ``mini-
hospital'' should require the full engagement of physicians competent 
in the care of complex, frail, older adults. A significant number of 
the nursing home deaths brought on by this virus were preventable. If 
there is an overarching message from the COVID-19 pandemic, it's the 
need to actively engage experts in geriatrics and long term care 
medicine in the policy and decision making processes that impact the 
lives of older adults. To the clinical experts this pandemic has never 
been about control, money or power. It's been about saving lives. 
Despite the Herculean efforts of experts in geriatrics and long term 
care medicine, we've literally had to beg for table scraps to weigh in 
on policies with county, state and federal government officials, much 
less the nursing home industry itself. Some have had a greater impact 
than others, but this never should have been this way. We must learn 
---------------------------------------------------------------------------
from this experience.

The evolution of nursing homes from post-war rest homes to today's 
``mini-hospitals'' began with implementation of the hospital DRG system 
in 1983. There was a brief period in which hospitals purchased nursing 
homes. They quickly realized that they could discharge patients to 
nursing homes without taking responsibility or accountability for the 
outcomes. Meanwhile, nursing home investors learned how to make 
substantial profits from Medicare and Medicaid without regard to 
quality of care. COVID-19 has unmasked a deeply flawed industry. The 
existing oversight of the nursing home industry has not worked to 
protect residents or staff during this pandemic. The survey process as 
implemented today does not work. It is time to lead the way in 
developing an effective oversight and quality improvement process. 
Surveys often worsen staff morale and have not been shown to have 
significant demonstrable benefit. The focus of surveys must be on 
improving the delivery of care and protecting the quality of life of 
the residents. We support active oversight, and believe that it is 
critical for CMS to engage experts in geriatrics and long term care, as 
well as resident advocates, in developing a new and more effective 
process for carrying out federally mandated surveys. An AMDA Task Force 
published a paper regarding this in the fall, and those of us who have 
served on the front line of nursing home care over the past few decades 
are ready and willing to engage in improving this important process.\9\
---------------------------------------------------------------------------
    \9\ Nazir A, Steinberg K, Wasserman M, et al., JAMDA, Time for an 
Upgrade in the Nursing Home Survey Process: A Position Statement From 
the Society of Post-Acute and Long-Term Care Medicine. 2020, ISSN 1525-
8610, https://doi.org/10.1016/j.jamda.2020.09.022.

Where does this leave us? This past summer the Coronavirus Commission 
on Safety and Quality in Nursing Homes met and produced a list of 
recommendations that settled on ten themes. Unfortunately, instead of 
acting on these recommendations, CMS leadership at the time chose to 
act as if they had already been following the recommendations. Nothing 
could have been further from the truth, which was alluded to in Mr. 
Dicken's testimony. I will proceed to review these recommendations as 
they form an excellent framework for how we might reimagine the nursing 
---------------------------------------------------------------------------
home industry as we go forward.

Testing and screening was ``Theme 1'' of the report. While the worst of 
the pandemic is over, and we now have vaccines, testing is still a 
critical issue, especially in regards to variants. A DPA level approach 
to testing should have been taken, and we still need that type of 
approach. With the ongoing growth of variants, it is essential that we 
aggressively sequence variants that are being found in nursing homes. 
From the beginning of this pandemic, it was essential to provide rapid 
turnaround of Pcr testing. Ideally, we should have point of care Pcr 
testing by now. It is unconscionable that all Pcr testing provided to 
nursing homes does not have less than 24 hour turnaround. In lieu of 
Pcr testing, antigen testing has provided an alternative approach to 
point of care testing. There are opportunities to provide home antigen 
tests to nursing home staff. The testing doesn't have to start and end 
with COVID-19. Similar tests are available for influenza and other 
viruses. We need to take advantage of what we've learned during this 
pandemic to reduce the impact of other deadly viruses that have plagued 
nursing homes in the past. There are continued opportunities to reduce 
both false negatives and positives.

Equipment and personal protective equipment were in ``Theme 2'' of the 
report. Every nursing home in the country MUST have an abundant supply 
of PPE. This is critical not only for COVID-19, but for other 
communicable diseases. Furthermore, N95s are essential, and no nursing 
home should ever be at risk of running out. There is a critical need to 
address supply chain issues so that they never occur again. There is 
also the need to assure that any financial support is effectively put 
towards PPE and testing equipment.

Cohorting was covered in ``Theme 3'' of the report. We have the 
opportunity to learn from our COVID-19 pandemic experience to evaluate 
the best ways to balance resident and staff safety with infection 
prevention and control. During the early months of the pandemic, the 
waiving of resident transfer and discharge requirements had many 
unintended consequences. For this reason, it is critical that evidence 
and science drive cohorting guidance.

Visitation was addressed in ``Theme 4'' of the report. While the 
decision to restrict visitation made immediate sense due to the lethal 
nature of COVID-19, it also contributed to social isolation. The 
consequences of social isolation have been found to have been 
significant. With the advent of fully vaccinated nursing home residents 
and the increasing percentage of staff vaccinations, we have turned a 
corner. But there is still a lot of work to be done in order to 
maximize safety when allowing visits to and from friends and family. 
Visitation is a vital resident right and nowhere is the collaboration 
between the CDC and CMS more critical. The term 
person-centered care is bandied about, but in order to make the care of 
nursing home residents truly person-centered we must fully engage 
experts in geriatrics and long term care medicine in developing the 
most effective approaches. CALTCM has used a modified Delphi process to 
make visitation recommendations,\10\ but in order to create expert 
driven guidance to fully address the risks and benefits of these 
approaches, CMS should convene similar groups of experts to assist in 
developing future guidance.
---------------------------------------------------------------------------
    \10\ Bergman C, Stall NM, Haimowitz D, Aronson L, Lynn J, Steinberg 
K, Wasserman M. Recommendations for Welcoming Back Nursing Home 
Visitors During the COVID-19 Pandemic: Results of a Delphi Panel. J Am 
Med Dir Assoc. 2020 Dec;21(12):1759-1766. doi: 10.1016/
j.jamda.2020.09.036. Epub 2020 Oct 7. PMID: 33256956; PMCID: 
PMC7539058.

Communications was ``Theme 5'' of the report. Throughout the pandemic 
ineffective communications have challenged the implementation of 
programs and guidance to nursing homes across the country. There needs 
to be increased specificity and expansion of guidance in regards to 
communications. While the concept of heath literacy is normally thought 
of in relation to interacting with patients, it also pertains to how we 
communicate with nursing home staff and the families of residents. In 
addition to effective guidance and communication with nursing homes, 
how the CDC and CMS communicate with each other also matters. Improving 
---------------------------------------------------------------------------
communications can be facilitated by fully engaging the QIN-QIOs.

The workforce ecosystem was ``Theme 6'' of the report. There are people 
in our society who are unable to be cared for at home. Older adults and 
younger disabled individuals requiring a nursing home level of care 
often have complex medical needs. Many have cognitive impairment or 
dementia. Most persons living in nursing homes need assistance with 
activities of daily living, whether it be for toileting and bathing, or 
for transferring out of a bed or chair. Meeting the needs of these 
residents requires an educated and well trained staff. The literature 
prior to and throughout the pandemic has been clear in relation to the 
need for appropriate levels of staff. A CMS study in 2001 established 
the importance of having a minimum of 0.75 registered nurse (RN) hours 
per resident day (hprd), 0.55 licensed nurse (LVN/LPN) hprd, and 2.8 
(to 3.0) certified nursing assistant (CNA) hprd, for a total of 4.1 
nursing hprd to prevent harm or jeopardy to residents.\11\ As part of 
this study, a simulation model of direct care workers (CNAs) 
established the minimum number of staff necessary to provide five basic 
aspects of daily care in a facility with different levels of resident 
acuity. A more recent study shows that for the highest acuity nursing 
homes, CNA staffing should be 3.6 hprd.\12\ For the lowest resident 
workloads, this converts to 1 CNA for every 7 residents on the day and 
evening shifts and 1 CNA to 11 residents at night. For the heaviest 
resident workloads, 3.6 CNA hprd converts to 1 CNA for 5.5 residents on 
days and evenings and 1 CNA for every 11 residents on nights.
---------------------------------------------------------------------------
    \11\ Centers for Medicare and Medicaid Services. Report to 
Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing 
Homes Phase II Final Report. Baltimore, MD: Centers for Medicare and 
Medicaid Services; 2001.
    \12\ Schnelle JF, Schroyer LD, Saraf AA, Simmons SF. Determining 
nurse aide staffing requirements to provide care based on resident 
workload: A discrete event simulation model. JAMDA. 2016; 17:970-977.

A number of organizations have endorsed the minimum of 4.1 hprd 
standard, and have suggested that at least 30 percent of hours should 
be provided by RNs and LVNs/LPNs and facilities should have 24-hour RN 
care.\13\, \14\, \15\ Some experts have 
recommended even higher staffing standards (a total of 4.55 hprd) to 
improve the quality of nursing home care, with higher adjustments for 
higher resident acuity.\16\ These numbers can not be a ceiling, but 
must become the floor. Efforts must be taken to ensure that nursing 
homes provide greater levels of staffing as appropriate based on 
acuity. The other issue that begs clear direction from CMS is in 
relation to having full-time Infection Preventionists. There should be 
a minimum of one full-time IP for all facilities with greater than 40 
beds, and the number of full-time equivalents should increase 
proportionally for facilities with greater than 100 beds. There also 
needs to be clear training guidelines and consideration of 
certification requirements for this position.
---------------------------------------------------------------------------
    \13\ Institute of Medicine. Keeping patients safe: transforming the 
work environment of nurses. Washington, DC: National Academy of 
Medicine, 2004.
    \14\ American Nurses' Association. Nursing staffing requirements to 
meet the demands of today's long term care consumer recommendations 
from the Coalition of Geriatric Nursing Organizations (CGNO). Position 
Statement 11/12/14, www.nursingworld.org.
    \15\ Coalition of Geriatric Nursing Organizations (CGNO). Nursing 
staffing requirements to meet the demands of today's long-term care 
consumer recommendations, 2013.
    \16\ Harrington C, Kovner C, Kayser-Jones J, Berger S, Mohler M, 
Burke R. et al. Experts recommend minimum nurse staffing standards for 
nursing facilities in the United States. Gerontologist. 2000; 40 (1):1-
12.

Workforce systems were ``Theme 7'' of the report. There has been a lot 
of discussion prior to and during the pandemic around a lack of 
interest for working in nursing homes. We clearly must address wages 
and benefits if we are to catalyze interest in becoming CNAs or having 
nurses work in nursing homes. It is time to overhaul the entire 
workforce ecosystem. The Commission recommended convening a LTC 
workforce commission. I concur with this recommendation, and would 
suggest that such a commission be tasked with quickly making actionable 
recommendations that can be implemented in the near future. There is 
also evidence that certified medical directors are associated with an 
increase in nursing home quality \17\ and there are many anecdotal 
reports of engaged medical directors making a difference during the 
pandemic. The average 99-bed nursing home is an approximately $10 
million per year complex business. Local nursing home leaders are 
rarely prepared to run such a complex business. The nursing home 
administrator is essentially the CEO of the business. What training is 
required to be a nursing home administrator? What about the director of 
nursing? They are the chief operating officer, managing and leading an 
inadequately trained and often poorly paid clinical workforce to 
provide care for some of the most complex persons in our history. A 
hospital organizational chart includes physicians at the highest 
levels. Where is such physician engagement in today's nursing homes? 
Effective teamwork and leadership from Medical Directors, NH 
administrators, and Directors of Nursing are critical for nursing 
homes, particularly in a pandemic, and ineffective teaming signals a 
critical need for leadership training.\18\, \19\ Variation 
in leadership style and high levels of turnover also impede the 
establishment of stable leadership in nursing homes.\20\ This then 
impacts staff turnover and quality of care.\21\ Enhancing leadership 
and management training for nursing home leadership teams is a key area 
that hasn't been fully discussed and desperately needs attention.
---------------------------------------------------------------------------
    \17\ Rowland FN, Cowles M, Dickstein C, Katz PR. Impact of medical 
director certification on nursing home quality of care. J Am Med Dir 
Assoc. 2009 Jul;10(6):431-5.
    \18\ https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.16513.
    \19\ Maas ML, Specht JP, Buckwalter KC, Gittler J, and Bechen K. 
(2008). Nursing home staffing and training recommendations for 
promoting older adults' quality of care and life: Part 2. Increasing 
nurse staffing and training. Research in Gerontological Nursing, 1(2), 
134-152.
    \20\ Williams G, Wood EV, and Ibram F. (2015). From medical doctor 
to medical director: Leadership style matters. British Journal of 
Hospital Medicine, 76(7), 420-422
    \21\ Donoghue C, and Castle NG. (2009). Leadership styles of 
nursing home administrators and their association with staff turnover. 
The Gerontologist, 49(2), 166-174.).

Historically, physicians have been engaged by nursing homes with the 
express purpose of helping to fill beds, or to satisfy a specific 
regulatory requirement. It is highly unusual for physicians to be 
engaged in facility leadership and operations. This concept would be 
anathema in the hospital setting, but has been readily accepted in the 
nursing home industry. AMDA, now called the Society for Post Acute and 
Long Term Care Medicine, was founded in 1977 and two years ago passed a 
resolution to the effect that the role of the nursing home medical 
director should have nothing to do with referrals.\22\
---------------------------------------------------------------------------
    \22\ https://paltc.org/amda-white-papers-and-resolution-position-
statements/policy-e19a-medical-director-compensated.

The American Board of Post-Acute and Long-Term Care Medicine provides a 
certification for nursing home medical directors. There are 1240 
nursing homes in California and only 125 certified medical directors. 
This percentage is similar nationally. The vast majority of medical 
directors in nursing homes around the country are not fully engaged 
with their facility leadership team. This has a negative impact on 
quality during normal times, but the impact has been amplified during 
the pandemic. Whether in dealing with COVID-19, or trying to provide 
quality care in the future, it is essential that the clinical experts 
be actively involved in the day to day operations of nursing homes. It 
is important that medical directors be allowed to perform their duties 
without undue influence from nursing home ownership. There should be no 
quid pro quo related to admissions, and medical directors should feel 
free to provide leadership and make recommendations regarding the 
delivery of care without fear of losing their position. One of my 
colleagues lost their medical director position early in the pandemic 
in order to be replaced by hospitalists who were perceived as providing 
a source of admissions to the facility. The best way to avoid such 
behavior would be to require certification for all nursing home medical 
directors. In California, Assemblyman Nazarian has introduced AB 749, 
requiring certified medical directors for every nursing home in the 
state. Until this happens at a national level, The Society for Post 
Acute and Long Term Care Medicine (AMDA) has requested that CMS create 
a registry of all medical directors in the country, so that we might 
directly communicate with them and offer resources and support for this 
---------------------------------------------------------------------------
vital role.

Technical assistance and quality improvement were ``Theme 8'' of the 
report. We must increase the availability of onsite collaborative, 
data-driven support. The QIN-QIOs must be effectively engaged. This 
means eliminating the need for QIN-QIOs to ``recruit'' nursing homes 
and to require them to participate. It is also necessary to reduce the 
QIN-QIO's administrative burden. Too much time and energy is spent with 
needless reports, when that time could be better spent with on-site 
training.

Facilities were ``Theme 9'' of the report. It is time for facility 
design enhancement. This includes addressing ventilation, space, 
capital incentives. It means considering approaches such as the Green 
House model.

Nursing home data was ``Theme 10'' of the report. There must be a 
comprehensive retrospective look at COVID-19 data beginning in January 
2020. We must capture the deaths related to COVID-19 (residents and 
staff), regardless of location at the time of death. There must also be 
an accounting of adverse events secondary to social isolation such as 
functional decline, weight Loss, pressure ulcers, and behavioral 
symptoms. Retrospective COVID-19 data must include a look at Pcr 
testing data (residents and staff), to include turnaround time, as well 
as an analysis of screening with and without outbreaks. Similarly, 
antigen testing data (residents and staff) must be similarly analyzed. 
Prospective data analysis must focus on genetic sequencing of variants 
and the value of both Pcr and antigen testing (staff and residents) in 
fully vaccinated nursing homes.

There is little disagreement regarding the fact that the financial 
structure of nursing homes is not conducive to maximizing scarce 
resources while providing quality care to residents. The separation of 
real estate, operations and management is a contrivance that leads to 
unmanageable pressures. The additional pressure from liability 
insurance costs compounds these pressures. It is time to bring 
transparent change to the ownership maze and consolidate nursing home 
ownership so that the full focus can be on delivering care to the 
residents. This is a complex topic that in and of itself is worthy of 
an entire tome. As someone who was the CEO overseeing the largest 
nursing home chain in California, it would be my privilege to testify 
before this committee on this topic. In the meantime, I would make a 
recommendation to help take the pressure off of nursing home operators 
during this challenging time. I suggest that nursing homes be exempted 
from paying rent and liability insurance premiums for the next six 
months. The costs of this would obviously be borne by the real estate 
owners and the insurance companies. I believe that it's time for them 
to do their part while we figure out how the nursing home industry can 
survive and come out stronger than it was before.

In order to imagine the future of nursing homes, picture a three-legged 
stool. If the three legs aren't equal, the stool will fall over. The 
legs represent Finance, Operations and Clinical Services. Rarely at the 
facility level or the corporate level of a large chain, are these 
treated equally. One will almost never find Clinical Services being 
given the same attention as Finance and Operations. This is the 
fundamental, and in the case of COVID-19, the fatal flaw in how today's 
nursing homes operate. If clinical services are not treated equally, 
the nursing home industry cannot, and I might say should not, survive.

Effectively providing care for a complex group of individuals requires 
competencies at every level of the organizational chart. Aside from 
having an appropriate level of staffing, nursing homes require properly 
prepared, highly skilled leadership teams that can balance the 
financial, operational and clinical aspects of this incredibly complex 
business. Which brings us to a specific roadblock that has prevented us 
from advancing beyond the status quo.

A recent study demonstrated higher mortality and higher taxpayer 
expenditures related to private equity in the nursing home 
industry.\23\ This study puts the impact of the pandemic in stark 
perspective. Today's nursing home industry attracts investors primarily 
because of its real estate and ``related party'' 
potential.\24\,\25\ As long as real estate is the primary 
driver of financial success, and related parties are allowed to siphon 
money away from operations, the nursing home industry as a whole will 
continue to fail to provide value and quality. The COVID-19 pandemic 
has demonstrated the importance of having immediate access to financial 
reserves, but those potential funds have been converted into real 
estate capital and private equity. That capital could have been 
effectively leveraged to provide for abundant PPE and testing as well 
as for additional staff. Instead, for the most part, that capital 
either sat on the sidelines or was leveraged for other purposes such as 
buying more real estate. If we are going to reimagine nursing homes, 
the clinical operations must have access to these funds.
---------------------------------------------------------------------------
    \23\ Gupta A, Howell ST, Yannelis C. Does Private Equity Investment 
in Healthcare Benefit Patients? Evidence from Nursing Homes. National 
Bureau of Economic Research Working Paper Series, No. 28474, February 
2021. 10.3386/w28474, http://www.nber.org/papers/w28474.
    \24\ Harrington C, Ross L, Kang T. Hidden Owners, Hidden Profits, 
and Poor Nursing Home Care: A Case Study. Int J Health Serv. 
2015;45(4):779-800. doi: 10.1177/0020731415594772. Epub 2015 Jul 9. 
PMID: 26159173.
    \25\ https://www.washingtonpost.com/business/2020/12/31/brius-
nursing-home/.

The Medicare Payment Advisory Commission produces highly precise 
reports of nursing home profitability that are based on the same 
illusion about the structure of nursing home finances. As the 
Government Accounting Office has demonstrated time and again, our 
government's attempts to secure quality and value from its investment 
have been outmaneuvered by private sector accountants and attorneys. We 
must illuminate and address the structural dynamics that successfully 
sustain the substandard status quo. In a recent Health Affairs 
Blog,\26\ we published a set of recommendations to address 
transparency. The tentacles of related parties have a negative impact 
on facility finances and operations. One of the unseen consequences of 
the existing related party structure is the upward pressure on costs 
that not only impacts for-profit nursing homes, but non-profits as 
well.
---------------------------------------------------------------------------
    \26\ https://www.healthaffairs.org/do/10.1377/hblog20210208.597573/
full/.

Oversight and enforcement are catch-all phrases that policymakers wield 
as solutions to poor quality in nursing homes. The government deploys 
its oversight strategies based upon an illusion that nursing home 
operators constitute the industry, ignoring the role of the real 
estate, related party owners and private equity. Applying penalties to 
the operations of nursing homes has not generally been shown to be an 
effective means for improving quality. The largest owners appeal and 
delay payments, sometimes for years, while non-profits and ``mom and 
pop'' nursing homes struggle under the weight of hefty penalties that 
may be misguided and don't support quality improvement. I recently 
participated in, and co-authored a paper making recommendations for 
upgrading the survey process.\27\ In my opinion, the only way to 
address this issue is to convene a Commission composed primarily of 
clinical experts, regulatory experts and advocates.
---------------------------------------------------------------------------
    \27\ Nazir A, Steinberg K, Wasserman M, et al., JAMDA, Time for an 
Upgrade in the Nursing Home Survey Process: A Position Statement From 
the Society of Post-Acute and Long-Term Care Medicine. 2020, ISSN 1525-
8610, https://doi.org/10.1016/j.jamda.2020.09.022.

Nursing homes are also weighed down by liability insurance costs that 
are compounded by this sector's perpetual quality issues. The insurance 
industry has little incentive to reduce premiums. Ironically, both 
plaintiffs' and defense attorneys have little incentive to see a change 
---------------------------------------------------------------------------
in the system. Nursing home liability must be thoughtfully reformed.

The nursing home industry and the government must also fully engage 
experts in geriatrics, post-acute and long-term care medicine, 
geriatric psychiatry, as well as experts in the care of the growing 
younger population of nursing home residents with disabilities and 
psychiatric conditions. Nursing home policy cannot be effectively 
imagined or implemented without these experts' active involvement.

The more subtle threats to the nursing home industry come from 
ignorance and arrogance. Ignorance related to the lack of understanding 
of how a geriatrics-focused, team-based approach to care is essential. 
Arrogance related to the fact that we can no longer keep running 
nursing homes as we have for the past four decades. If we are to 
reimagine nursing homes, we must be certain that the clinical focus is 
never allowed to be subservient to the finances. The entire industry 
must be reimagined. We must start by assuring appropriate staffing. The 
staff must be trained and must earn a living wage with corresponding 
benefits, and turnover must be reduced. Leadership teams must set their 
primary focus on providing quality care. We cannot afford money being 
siphoned out of facilities toward excessive real estate, related party 
and insurance industry profit. The residents we care for deserve to be 
prioritized. After nearly a year of hell, where all have been cut off 
from their loved ones, and many have lost their lives, we owe them that 
much.

I want to close by reiterating the fact that experts in geriatrics 
across the country would relish the opportunity to assist in the 
development of policy related to the health and well-being of frail 
older adults. This is what we've spent our lives training for. Many of 
us were inconsolable as the federal government, the Departments of 
Public Health and many counties made decisions without the full input 
of the clinical experts throughout this pandemic. It is time to learn 
from these mistakes and develop a structure that allows for the 
development of expert-driven policy. I plead with you to find a way to 
encourage the direct involvement of the experts as we move forward. If 
such a process had already been in place, a significant number of lives 
would have been saved.

                                 ______
                                 
                   Letter Submitted by Rachel Winters
Dear esteemed representatives:

I am a registered voter in Pennsylvania (Westmoreland County) and I am 
writing to share my story, like others across the Commonwealth, who 
have family in assisted living/long term care facilities. The 
restrictions during the COVID pandemic placed on these facilities by 
the Pennsylvania Department of Health, CDC, and Centers for Medicare 
and Medicaid have adversely affected the quality of life for the 
constituents that rely on these facilities for their care.

My father, Herbert Henderson, is a veteran of the United States Air 
Force and proudly served his country in Vietnam. In November of 2019, 
my father had a series of strokes that impaired his speech and 
mobility. He was in and out of hospitals and rehabilitation facilities 
spending a total of 14 days at home since November 26, 2019. We placed 
him at Saint Anne's Home in Greensburg, PA on March 8, 2020 for further 
physical and occupational therapy. Saint Anne's was shut down on March 
13, 2020 because of the COVID-19 outbreak. My family decided to let my 
father complete his therapy at Saint Anne's and wait to see if we could 
witness his progress to determine if my 75 year old mother could care 
for him at home. That opportunity never came.

We had to send my father to the hospital twice during the COVID 
pandemic, once in May for congestive heart failure and again in July 
for colitis and C. Diff. Each time we had to weigh the decision to send 
him out knowing that he would be in quarantine for 10-14 days upon 
returning to Saint Anne's. Each time he had to quarantine after a 
hospitalization was excruciating. He would become agitated, his speech 
was slurred and difficult to understand, and the last hospitalization 
he lost the ability to feed himself with utensils.

The first time my father was able to go outside was for a table visit 
in August, 3 months after arriving to Saint Anne's. The facility is 
hard pressed to retain staff given the current health crises, so there 
isn't enough people to get him outside to enjoy the sunshine on his 
face or hear the birds in the trees. This is something we did with him 
every time we visited for the short period we were allowed in the 
building. We went up every day, for two hours and made sure he got 
outside in one of Saint Anne's beautiful gardens. My dad loves to be 
outside.

My family and I have followed every protocol and abided by every 
changing rule and regulation sent down by the state and the CDC. We 
were allowed 2 compassionate care visits with my dad and 13 table 
visits which were 20 minutes in length, with an 8 foot table separating 
us.

Despite the frequent COVID tests of staff, not seeing family/friends, 
and the severe reduction in social activities, my father contracted 
COVID-19 the end of November 2020. He was isolated in his room for 3 
weeks with the door shut and covered in plastic. The only view he had 
was to an interior courtyard, which meant that we could not visit. The 
ventilation system in his room that was to circulate air and prevent 
the virus from getting into the building made it impossible for him to 
hear us on the phone. Not only could we not see him, we couldn't talk 
to him either. The only interaction he had was with the nurses and 
aides who worked at Saint Anne's, many whom were unfamiliar to him 
because his usual care staff had also contracted COVID. He spent 
Thanksgiving alone in his room. When he was finally released from 
isolation, he was a shell of a man. My mom and I went up for our usual 
window visit and he wouldn't speak to us, just staring out into space.

The lack of stimulation via activities, communal dining, and personal 
contact is taking a toll on all residents in personal care/long-term 
care facilities. These individuals haven't committed any crimes and yet 
they are being punished for getting old, frail and sick. These homes 
are understaffed and overwhelmed trying to keep up with the regulations 
and rules placed upon them. It is an extreme disservice to the people 
in these facilities, their families, and the staff that we are over a 
year into this pandemic and there is no end in sight. The COVID 
pandemic is killing off the elderly not by contracting the virus, but 
by disengaging them for everyday life. They are sitting in their rooms 
in front of a TV waiting to die.

In December, we were notified that my father isn't doing well. He 
hadn't eaten anything for 3 weeks; he ripped out the IV meant to 
provide him hydration; he was refusing blood work and his medications; 
he was telling everyone at Saint Anne's that he wants to die. We were 
advised to sign him up for hospice because he is in the twilight of his 
life. We were allowed two compassionate care visits and one tent visit 
when his conditioned worsened. Then the infection rate in Westmoreland 
County increased and based on the regulations we are not allowed in 
Saint Anne's to see my dad. We got to watch him slowly deteriorate 
through a pane of glass.

My mom and I have been up at my dad's window at 3-5 days a week since 
the lockdown for at least an hour. We were sitting out there in the 
rain, snow, and freezing temperatures. We want him to know that he is 
not forgotten. He doesn't understand why we can't come in there and sit 
next to him on his bed or hold his hand.

Countless birthdays, holidays, and anniversaries were spent either 
looking at my father through a closed window or separated by an 8 foot 
long table with a Plexiglas barrier. No touch. No physical contact. An 
entire year has gone by without being able to take my dad outside to 
one of the courtyards to hear the birds sing or walk him up and down 
the halls of the facility. My parents have been married 57 years. This 
is the longest that they have not been physically together since my dad 
was in the Air Force and deployed.

When he was admitted to Saint Anne's he was walking with a walker, able 
to feed himself, and called us on his cellphone. Now a year later, he 
requires two people and a lift to get him in and out of bed. He no 
longer remembers how to answer his phone, let alone call us to talk. 
His fine motor abilities have declined. I take him finger foods and 
watching him trying to pick up his food is painful. He has lost 40 
pounds this year. His speech also suffered. He is hard to understand, 
even on his best days.

Thankfully he has improved since December. Saint Anne's started to lift 
some restrictions based on the new CMS guidelines. We were scheduled to 
see him in his room March 17 and 19, but a staff member tested positive 
for COVID and we were no longer allowed in the building. We instead had 
2 tent visits scheduled for 30 minutes.

Would have things been different if we were allowed to be with him all 
this time? Has he given up the will to live because of the current 
circumstances or is it just a progression of his illness? We may never 
know, but these questions will linger with us for a lifetime.

My family may not personally benefit from any efforts made by you on 
our behalf, but I don't want other families to go through this. The 
last year has been pure hell. I was hoping with the vaccine things 
might change.

These protocols and regulations may have looked good on paper to 
prolong life and decrease infection in residential facilities, but the 
realities are something all together different. While the protocols may 
have prolonged the quantity of life, they has drastically impacted the 
quality of life.

I'm sure there will be another virus or health crisis in the future. 
It's inevitable. This can not happen again. The complete closure of 
these facilities and lack of access to loved ones is cruel and unusual 
punishment. Our seniors deserve better.

Sincerely yours,

Rachel Winters

                                  [all]