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President Clinton Announces New, $1 Billion Investment in Nursing Home Quality Takes Additional Steps to Increase Staffing and Accountability in Nursing Homes


September 16, 2000

Today, in a live radio address broadcast from The Washington Home in Washington, DC, President Clinton will announce that he will be sending legislation to the Congress next week to improve nursing home quality nationwide. This initiative: (1) invests $1 billion over 5 years in a new grant program to increase staffing levels nationwide and improve quality of nursing home care; (2) imposes immediate penalties on nursing facilities placing residents at risk and reinvests these funds in the new grant program; (3) directs the Health Care Financing Administration to establish national minimum staffing requirements and complete recommendations for appropriate reimbursement within two years; (4) helps families make informed decisions by providing accurate information on staffing levels; and (5) launches a new campaign to identify and prevent unintended weight loss and dehydration among nursing home residents. He will state that these proposals can and should be included in any legislation that increases funding for health care providers being considered by the Congress. The President will praise Senators Grassley and Breaux, as well as Congressmen Gephardt, Waxman, and Stark, for their leadership on this issue and encourage the Congress to act quickly on this new initiative.

MORE MUST BE DONE TO IMPROVE QUALITY OF CARE IN NURSING HOMES. About 1.6 million older Americans and people with disabilities receive care in approximately 17,000 nursing homes. The Clinton-Gore Administration has made the health and safety of nursing home residents a top priority implementing the toughest nursing home regulations in the history of the Medicare and Medicaid programs. Many nursing homes provide high quality care to the frail and vulnerable elderly individuals they serve. However, recent reports have demonstrated a strong correlation between inadequate staffing and poor quality of care. Specific findings include:

  • Over fifty percent of nursing homes do not maintain the minimum staffing levels necessary to ensure the delivery of quality care. The Health Care Financing Administration (HCFA) recently released a report demonstrating that patients are significantly more likely to develop pressure sores, lose weight, and undergo unnecessary hospitalizations once staffing ratios fall below the level of two hours per resident for certified nurse aides daily. That amount of time is the minimum necessary for nursing staff to reposition residents and change wet clothes; assist residents with toileting; provide feeding assistance; provide morning care; and encourage or assist residents with exercise as appropriate.
  • Poor staffing results in many nursing home residents becoming malnourished or dehydrated, unnecessarily increasing their risk of infection and impaired mental function. Certified nursing assistants (CNAs) typically help seven to nine residents with their daytime meals, and as many as 12 to 15 residents with their evening meals. A recent study by the Commonwealth Fund estimates that over 30 percent of nursing home residents are malnourished, placing them at risk for infections, pressure sores, depression, confusion and impaired cognition, and hip fractures. Compared with well hydrated and nourished residents, these nursing home patients have a five-fold increase in mortality when admitted to the hospital.
  • Nursing home staff often need additional training to carry out their assigned duties adequately. A 93 percent turnover rate in CNAs compounds the problems caused by inadequate numbers of nursing home staff. A shortage of nursing supervisors leaves CNAs to do the best they can without assistance from registered nurses or physicians.


  • Invest $1 billion over 5 years in a new grant program to improve quality of nursing home care. This portion of the initiative, which is financed through the undedicated portion of the President's $40 billion provider restoration initiative and should be included in any such initiative being considered by the Congress, will:
  • Create a competitive grant program to increase staffing levels in nursing homes nationwide. States would be able to receive funds to provide financial and technical assistance to nursing facilities, unions, non-profit organizations, or community colleges. States applying for funds would be required to develop, through an open public process, a proposal to enhance staff recruitment and retention efforts; establish career ladders for CNAs; provide increased training for staff; or conduct other staffing initiatives to assure improved patient outcomes as approved by the Secretary of Health and Human Services. States may also use a portion of the funds to reward nursing facilities with exemplary quality of care records. At least 75 percent of funds are to be awarded to states whose current staffing levels are below two hours per resident for certified nurse aides daily, but who commit to raising their staffing levels to the two hour level within two years. Up to 25 percent of the funds are reserved for states whose staffing levels are currently at or above the two hour threshold. This legislation requires the Secretary to increase the staffing thresholds as recommended by the upcoming HCFA report on staffing levels with the goal of reaching the staffing level necessary to provide optimum care.
  • Imposes immediate penalties on nursing homes endangering patient safety. Currently, if a nursing home appeals the imposition of a fine for endangering patient safety (G level violation), the Federal government does not collect the fine until after the appeal is settled, allowing many facilities to avoid paying fines for years after the violation was committed. This initiative would require civil money penalties to be immediately withheld from future payments to the nursing home. If a nursing home appealed the imposition of the fine and won, the Federal government would return the funds with interest.
  • Invests Federal financial penalties levied against nursing homes endangering patients in the new grant program. Any civil money penalties collected by the Federal government will be automatically reinvested in the new $1 billion grant program and used to improve the quality of care provided to nursing home residents rather than returned to the Medicare Trust Fund.
  • Providing the public with accurate information on staffing levels. Nursing homes participating in the Medicaid and Medicare programs will be required to provide HCFA with detailed information on their current staffing levels, including the total number of hours; coverage levels per shift; identifying staff as CNAs, LPNs or RNs; and the average wage rate for each class of employees. This information will be posted for the public to review in individual facilities as well as on HCFA's Nursing Home Compare website.
  • Direct HCFA to establish national minimum staffing requirements within two years. Today, the President will direct HCFA to complete its comprehensive study on staffing ratios within 12 months and develop and publish Federal regulations establishing minimum staffing levels no later than September 1, 2002. As part of this process, HCFA will concurrently evaluate whether any changes in Federal reimbursement are necessary to implement the new staffing standards established by the report. In addition, HCFA will include a recommendation on the feasibility and advisability of increasing training requirements for CNAs from 75 to 160 hours.
  • Launch a new campaign to prevent unintended weight loss and dehydration among nursing home residents. This week, HCFA launched a new education campaign that is sending all 17,000 nursing homes in the country a new set of training materials to identify and prevent malnutrition and dehydration. These materials will help CNA and other caregivers identify residents at risk for unintended weight loss and dehydration and then take the necessary action to prevent it.

PRAISES A BIPARTISAN CONTINGENT OF MEMBERS FOR THEIR LEADERSHIP IN IMPROVING NURSING HOME QUALITY. Senators Grassley, Breaux, Reid, and Kohl, as well as Congressmen Gephardt, Waxman, and Stark, have shown exemplary leadership on this issue and their efforts to improve nursing home quality nationwide.

BUILDS ON THE CLINTON-GORE ADMINISTRATION'S STRONG COMMITMENT TO IMPROVING NURSING HOME QUALITY. Protecting patients in nursing homes has been and will continue to be a priority of the Clinton-Gore Administration. In 1995, the President threatened to veto legislation pending before the Congress that would eliminate Federal enforcement of nursing home quality standards, and issued the toughest nursing home regulations in the history of the Medicare and Medicaid programs, leading to measurable improvements in quality of care for nursing home residents. In July of 1998, the Clinton-Gore Administration initiated a new nursing home quality initiative that ensures swift and strong penalties for nursing homes failing to comply with standards, strengthened oversight of state enforcement mechanisms, and implemented unprecedented efforts to improve nutrition and prevent bed sores. Finally, the Administration recently instructed states to eliminate corrective periods during which nursing homes could avoid the imposition of sanctions, such as fines, when a nursing home is found to have caused harm to a resident on consecutive surveys, in order to put additional pressure on nursing homes to meet all health and safety standards.

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