When we first learned of widespread incidence and deaths from COVID-19 in a Seattle-area nursing home, many in the aging and health care fields already knew what was ahead. Since early March, Missouri, California, Texas, New York, Florida, Pennsylvania and nearly every other state have reported cases, More than 5,500 nursing home residents had died from coronavirus-related conditions as of April 15.
The real number undoubtedly is higher, since the Centers for Medicare & Medicaid Services only recently announced new regulatory requirements to report cases of COVID-19 directly to the Centers for Disease Control and Prevention. Many deaths early in the pandemic likely were attributed to age-related complications from flu, pneumonia, or pre-existing heart and breathing problems. So how are states helping to protect their most vulnerable residents?
An update from CMS on April 30 detailed the various waivers and new rules issued to date for long-term care and skilled nursing facilities. According to the statement, these rules, including long-term care reporting requirements, were effective immediately upon issue:
“Under the new §483.80(g), CMS is requiring facilities to report COVID-19 cases in their facility to the CDC National Health Safety Network (NHSN) on a weekly basis. CDC and CMS will use information collected through the new NHSN Long-term Care COVID-19 Module to strengthen COVID-19 surveillance locally and nationally; monitor trends in infection rates; and help local, state, and federal health authorities get help to nursing homes faster. Nursing home reporting to the CDC is a critical component of the national COVID-19 surveillance system and to efforts to reopen America. The information will also be posted online for the public to be aware of how the COVID-19 pandemic is affecting nursing homes.
Facilities are also required to notify residents, their representatives, and families of residents in facilities of the status of COVID-19 in the facility, which includes any new cases of COVID-19 as they are identified. This action supports CMS’ commitment to transparency so that individuals know important information about their environment, or the environment of a loved one.”
The full regulation is further detailed in documentation slated for publication in the Federal Register on May 8. According to a CMS spokesperson, “We plan to issue the data soon.”
Maryland has formed a “strike team” comprised of the state’s National Guard and personnel from each of the state’s four hospital systems, according to Timothy Chizmar, M.D., the state’s emergency medical services medical director. “The facility interacts with their county health department and identifies a need for help and we route that request to our state of emergency operations center,” he said during a recent webinar sponsored by the National Academies of Medicine.
The operations center dispatches an assessment team of physicians, nurses and behavioral health support specialists from the Maryland National Guard to assess the needs of the facility and the patients, then help stabilize any medical issues. Residents needing transport to a hospital are identified; the rest are treated on-site by a clinical team from a participating hospital system.
“They also provide reassurance to the staff in helping to treat these patients in the environment in which they’re most comfortable,” said Chizmar, noting that the approach seems to be working. “In the course of all of our work, we’ve been able to avert to large scale evacuations of nursing homes by stabilizing and providing temporary staffing until staffing agencies were able to come behind us. And I think that’s been one of our great successes — not having patients transferred unnecessarily for lack of staffing.”
Multiple media reports say that nursing home staff throughout the U.S. came to work even when ill. Some knew they were sick and came anyway because they needed the income. Others who may have been asymptomatic also may have worked at more than one facility, further spreading the disease. Also, many facilities lacked enough testing kits and had limited personal protection equipment.
“I truly believe that most of this transmission is asymptomatic staff,” said Morgan Katz, M.D., M.H.S., director of antimicrobial stewardship at Johns Hopkins Bayview and an assistant professor of infectious disease at Hopkins School of Medicine. “It’s sort of a Catch-22 because when we test the staff, that often results in them having to be out. Then you have more staffing issues because you have to contract too many staff that are outside of your facility and you have more crossovers staff in several facilities.”
The situation is becoming increasingly problematic as some nursing homes are forced to accept COVID-positive patients discharged from hospitals — even if they are not equipped to deal with such an influx, The New York Times reported. Additionally, infection control remains a significant issue in nearly half the homes with reported cases, according to this Washington Post story. The Post regularly updates this list of facilities with reported cases.
Massachusetts is another state taking more proactive measures. A staffer is assigned to every nursing home with at least one positive case, contacting it at least every other day to check in about staffing, supplies and challenges in meeting best practices, according to Alice Bonner, Ph.D., R.N., director of strategic partnerships for the CAPABLE program and an adjunct faculty member at the Johns Hopkins School of Nursing.
“We get information back to the state and the nursing home gets some support,” she said during the webinar.
Almost all nursing homes (and most assisted living and retirement communities) throughout the U.S. are on some level of lockdown. Employees are temperature-checked and queried about social contacts before entering a facility, and infection control is now a key priority of CMS inspectors. But it may be too little, too late.
According to this investigation by ProPublica, it’s not been just staffing at issue. Federal inspection reports show many homes already had lax infection control standards before the pandemic and did not act quickly enough when residents began showing signs of having developed COVID-19. This allowed widespread transmission to vulnerable residents.
Adding to oversight concerns is that CMS’ interim rules bar friends, family, and even ombudsmen from entering a facility to see for themselves whether proper infection control measures are in place. Some families may not even learn a loved one is ill or has been transferred to a hospital or other facility until after the fact. A story in Barron’s calls it a crisis.
Elder advocates are up in arms over lack of information. The American Health Care Association, which represents nursing homes and assisted living facilities, pushed back, arguing that facilities are doing the best they can in impossible circumstances.
Families wait and wonder. Residents are afraid. And several states have been less than forthcoming with data. There are many dedicated nurses, aides, physicians and support staff who are doing all they can to keep residents safe. But without transparency, without knowing where the problems are, how can we be sure that those most vulnerable to the virus are truly protected?
Journalists interested in this story should speak with resident advocates and nursing home ombudsman to learn if they’re hearing from families. Here are some questions to get answered:
- If your state is not releasing more detailed information, keep asking why not. File a FOIA request if necessary — you should be able to find out the names of facilities without violating resident’s privacy. Check in with AHCJ’s Right to Know Committee, which can help steer you in this process.
- In addition to new CMS guidance, what additional rules is your state enacting to protect its nursing home residents?
- Which area nursing homes previously were cited for infection violations? Were those corrected before the pandemic? Did residents or family know about them? ProPublica’s Nursing Home Inspect website can provide a wealth of data about this and other violations.
- What is the status of other health or safety violations at facilities? How are those being addressed, if at all, during this crisis?