• Gwen Cunningham

We Need to Return to Implementing Evidence-Based Practices in Nursing Homes

The following is adapted from BROKEN, published on Book Bites.


None of us ever want to think we’ll spend our remaining years in a nursing home. In fact, most of us shudder at the thought, because nursing homes have such terrible reputations.

We don’t like them. The media doesn’t like them, and the regulators believe the care is bad.

Now add a global pandemic to the mix of this already challenged, underfunded, and under-resourced healthcare environment, and you have a perfect catastrophic storm. The response? Apathy and disdain.


The Regulatory Process is Ineffective and Broken

“We’ve seen ambivalence toward nursing homes for years,” Dr. Konetzka, who serves on the technical expert panel that advises CMS on the Nursing Home Compare website and five-star rating system, told me when I interviewed her. Then, she went on, saying, “This pandemic was not in the nursing homes’ control. Research came out showing that the virus was widespread in a nursing home when the community rates were high.” Katie Smith Sloan, CEO of the national nursing home advocacy group Leading Age, put it this way: “We’ve never had a virus before that was airborne and largely asymptomatic. The public health guidance was changing day by day […] and we were learning as we went. In the hospital, if something happens, it’s an accident or mistake. In the nursing home, it’s an infraction. Nursing homes have been unfairly maligned, and so many of them are doing such a fantastic job with such high stakes.” Ultimately, nursing homes are currently more regulated than any other healthcare provider types, including hospitals and outpatient care settings. There’s constant legislative pressure to add more and more regulations and rules to ensure that appropriate care is being delivered. Meanwhile, enforcement of these regulations is ineffective and broken.

Surveyors Contribute to the Problem

Part of the problem is that surveyors from federal and state regulatory agencies aren’t appropriately trained. Whether a nursing home gets tagged depends on which surveyor is in the facility. However, the other problem is that, in many instances, surveyors are dictating policy — even when they aren’t qualified to do so. As a consultant in the field of public health and infection prevention, I never thought a licensing agency would dictate my professional recommendations. But during this pandemic, I’ve found myself more often telling the nursing home staff to follow certain protocols, even if they don’t make sense or contradict each other, to avoid a state citation. This subjective mindset is pervasive across the country. Josh, an Idaho administrator, described how some nursing homes continue operating based on a citation they received 25 years ago. He’s right. In the nursing home I helped Josh with, they had gotten a citation years prior for having alcohol-based hand-sanitizing dispensers in the hallway. Their response was to never put them up again, even though this is now a CDC recommendation. There’s also a fear component, Josh said. When you get a citation or a tag, it’s a big deal that affects the facility’s reputation. “But,” he continued, “the opposite effect can be true as well. If a surveyor skims over everything without drawing appropriate attention to issues, then the nursing home believes they’re doing well.”



A Good Survey Does Not Mean Things Are Okay

Before COVID-19, when I was offering nursing homes support to improve their infection prevention and control program, I heard time and time again, “No, we don’t need any assistance. Our state survey was good.” These nursing homes, based on their survey, truly believed they were good with their program. Given the catastrophic nature of COVID-19 in this healthcare setting, we can venture to say they were not okay, regardless of what their state survey said. Over time, as a solution to one or two incompetent nursing homes that make national news, the survey process has become bigger, stronger, and more in-depth. The more in-depth it gets, the harder it is for the nursing homes to comply or for the surveyors to be competently trained to regulate a facility appropriately.

Over-Regulation Leads to a Crisis Mentality

Unfortunately, this over-regulation tends to support a crisis mentality: “Snap, fix this, no, go fix this,” and “Whack-a-mole over here because the surveyors are coming.” Is this overregulated system driving good people away from the industry? “It’s pretty difficult to maintain good MDs in the field,” Josh told me. “I can’t tell you how many doctors I’ve seen argue with surveyors. The surveyor may be a registered dietician and argue with a medical doctor with 20 years of experience, claiming they didn’t write an order correctly. In what world is that okay?” Ultimately, all of this makes one thing very clear: we need to return to implementing evidence-based practices and get away from a system driven by surveyor opinions.



For more advice on how to get away from a regulatory system driven by surveyor opinions, you can find BROKEN on Amazon.


Dr. Buffy Lloyd-Krejci is one of the nation’s foremost authorities on infection prevention and control in nursing homes and long-term care facilities. Her Phoenix-based practice, IPCWell, is devoted to reducing infections, antibiotic resistance, re-admissions, and death in healthcare settings across the country and around the world. A frequent contributor and interview source for national and trade press concerning infection prevention, control, and mitigation, she has appeared in Cambridge University Press, in Skilled Nursing News, and on National Public Radio, among others. For more information, visit IPCWell.com.

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