Coronavirus Commission for Safety and Quality in Nursing Homes Report

by Patty Klinefelter, Director on September 23, 2020

Nursing home residents and staff account for approximately 41% of COVID-19 deaths. Because of this, the Centers for Medicare & Medicaid Services (CMS) convened a task force of experts, the Coronavirus Commission for Safety and Quality in Nursing Homes (Commission), to study the quality of care in nursing homes related to the COVID-19 pandemic and make recommendations to improve infection control practices and overall quality of care of nursing home residents.




The task force had 25 Commission members with diverse backgrounds including nursing home residents, nursing home administrators and owners, infectious disease experts, academics, state authorities, and consumer advocates. CMS provided the Commission with four objectives:

  1. Identify best practices to enable rapid and effective identification and mitigation of COVID-19.
  2. Recommend best practices for rigorous infection control practices that serve as a framework for enhanced oversight and quality monitoring.
  3. Identify best practices for improved delivery and responsiveness to the needs of the nursing home residents during an emergency.
  4. Leverage data to improve infection control policies and enables coordinated efforts between federal, state, and local entities.

Last week, CMS released the Commission Final Report issued by MITRE, the research firm commissioned by CMS. Ten themes were identified with 27 recommendations, including action steps. For each theme there is an analysis including an overview of relevant findings and evidence, specific action steps to implement for each recommendation, and information about the Commission’s endorsement. The ten themes identified are:

  1. Testing and Screening
  2. Equipment and Persona Protective Equipment (PPE)
  3. Cohorting
  4. Visitation
  5. Communication
  6. Workforce Ecosystem Resident Safety
  7. Workforce Ecosystem Strategic Reinforcement
  8. Technical Assistance and Quality Improvement
  9. Facilities
  10. Nursing Home Data

The ten themes addressed the Commission’s four objectives and reflect responses to the following:

  • Ongoing supply and affordability dilemmas related to testing, screening, and PPE
  • Tension between rigorous infection control measures and quality of life issues that exist in cohorting and visitation policies.
  • A call for transparent and accessible communications with residents, their representatives and loved ones, and the public.
  • Urgent need to train, support, protect, and respect direct-care providers.
  • Outdated infrastructure of many nursing-home facilities.
  • Opportunities to create and organize guidance to owners and administrators that is more actionable and to obtain data from nursing homes that is more meaningful for action and research.
  • Insufficient funding for quality nursing home operations, workforce performance, and resident safety. 

Key Takeaways as Noted in the Report

Immediate and near-term actions by CMS (through policy or regulations, alone and with others) are necessary. The Commission and the public alike call on CMS to continue advocating on behalf of beneficiaries based on the following principles.

  • Residents and families must be able to connect in meaningful ways. This is to ensure the physical and mental well-being of the residents to protect against neglect and abuse. To achieve positive outcomes, CMS must ensure nursing homes address this need and any other conditions while prioritizing rigorous infection control.
  • Nursing home staff must be kept safe and treated with respect in the workplace. This requires access to the right training and equipment, along with compensation that recognizes the risks they take, their dedication to resident safety, and the quality of care they deliver.
  • Nursing home management and staff can be more effective if provided with streamlined communications, reporting capabilities, and access to funds. This can support additional costs and can reduce the trauma of some emergency measures by communicating policies in advance and providing advance notice when activated. 

The Commission is recommending that CMS work with its partners to identify sufficient funding to fully pay for each of the implemented recommendations. The Commission is also recommending that CMS start taking steps to solve longer-standing, systemic issues illuminated by the pandemic. A focus on long-term care financing and accountability, facility design, workforce, governance and management, technology, and data will help ensure future nursing home safety and quality.

As the Commission’s recommendations are considered, regulations may change. Stay tuned for more information, as this is an evolving process.

How Can LW Consulting, Inc. Help?

Infection control is critical due to the public health emergency (PHE) and COVID-19. LW Consulting, Inc. (LWCI) has experts in infection control and team members with Centers for Disease Control Infection Preventionist certifications. We also have expertise in assisting providers with environmental services as it relates to infection control.

Our team of experts are conducting mock infection control surveys and assisting with the development and revisions of infection control policies, procedures, and processes. We also provide education for nursing home staff.


Do you need help ensuring your employees and residents stay COVID-19 free? Contact Patty Klinefelter at 540-686-1311 or email

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Topics: Compliance, Leadership & Staffing