With the nation’s goodwill directed at hospitals during the coronavirus disease 2019 (COVID-19) pandemic, nursing homes became caught in a critical catch-22. Their initial pleas for personal protective equipment (PPE), diagnostic tests, and staffing support went largely ignored. Months into the crisis, as some facilities still scrounged for supplies and staff, the federal government announced phased guidance for reopening nursing homes that hinges on the very resources they don’t have.
The May 18 recommendations from the Centers for Medicare & Medicaid Services (CMS) aim to direct state and local officials in relaxing restrictions for the nation’s more than 15 000 nursing homes, whose 1.3 million residents are locked down without visitors, communal meals, or group activities. They call for having adequate PPE on hand and regularly testing staff and residents for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) before ending lockdowns.
Yet industry experts and representatives warned that these benchmarks will be impossible to meet without federal coordination—largely nonexistent to date—that includes a massive influx of additional funding, supply chain improvements, and manpower.
The new guidance is “urgently needed,” said Terry Fulmer, PhD, RN, president of The John A. Hartford Foundation, which supports evidence-based care for older adults. But without the ability to obtain reliable testing and PPE, she said in an email, “these recommendations are not realistic.”
Days after the CMS released its guidance, the US Department of Health and Human Services announced $4.9 billion in aid for skilled nursing facilities. Although industry leaders welcomed the $50 000 plus $2500 per bed for each facility, they said the funding falls short of actual needs across the long-term care continuum, including assisted living.
In a statement, Katie Smith Sloan, president and CEO of LeadingAge, an organization that represents nonprofit nursing homes and other aging services, called the new funds “a start” but said they “will only go so far in addressing providers’ growing financial needs as this pandemic continues.”
“Abandoned”
On June 4, the CMS reported almost 154 000 confirmed and suspected COVID-19 cases and almost 32 000 deaths in skilled nursing facilities, with 88% of homes providing data. The numbers across long-term care were worse. According to the Kaiser Family Foundation, states reported more than 217 000 COVID-19 cases and almost 44 000 deaths in nursing homes, assisted living, and other aging care facilities by early June, representing at least 40% of total US deaths. And in 26 states, at least 50% of COVID-19 deaths were in long-term care facilities as of May 28.
The figures illustrate the lethal mix of a highly contagious new virus; older, vulnerable residents who usually require intimate, close care; an industry with long-standing shortcomings, especially around infection control procedures; and the ubiquitous shortage of PPE and testing.
In fact, those shortages may have factored into outbreaks, according to Ghinwa Dumyati, MD, who directs communicable disease surveillance and prevention at the University of Rochester Medical Center in New York. Christopher Laxton, executive director of the Society for Post-Acute and Long-Term Care Medicine, known as AMDA, agrees. “These constraints not only contributed to outbreaks, they made it difficult if not impossible to control the outbreaks once they occurred,” he said.
Despite an early understanding that older adults with comorbidities were at greatest risk, “initially, nursing homes were not prioritized,” Laxton said. “Hospitals came first.” In one notable example, the medical director of Canterbury Nursing Home in Virginia said his facility was short on N95 masks during an outbreak that killed 49 people and infected 60% of residents because supplies had been diverted to hospitals.
Nursing home representatives and researchers alike have observed that the widespread PPE and testing shortages have gotten far too little attention amidst a plethora of negative news coverage. Facilities and staff “have felt abandoned,” Fulmer said.
The help that has since come has been too little, too late. Late April news reports that the Federal Emergency Management Agency (FEMA) would ship limited PPE to nursing homes was the “first sign in months” that the industry’s pleas were being heard, LeadingAge’s Smith Sloan said in a critical statement.
FEMA announced it would send 2 one-week shipments directly to nursing homes by the end of June. But at least some facilities received even less than a 1-week supply in the first shipment, according to LeadingAge. A nursing home in the Washington, DC, area that needs 1400 gowns per week for its staff received just 432 in a May 12 shipment believed to be from FEMA. An employee reported that the shipment also included inadequate amounts of eye protection, surgical masks, and gloves. The agency is not supplying N95 masks, face shields, hand sanitizer, or wipes.
Groups including the American Geriatrics Society (AGS) and LeadingAge have asked the Trump administration to use the Defense Production Act to increase PPE and COVID-19 test availability for long-term care facilities. The sheer quantity of supplies that nursing homes need to prevent and control outbreaks can be hard to fathom.
At May press events organized by LeadingAge, nursing home leaders said staff were spending 100 hours a week sourcing PPE and meeting dealers in parking lots to obtain supplies. Sources say gowns are in particularly short supply, with some workers wearing rain ponchos and trash bags or designating gowns to be reused with either COVID-19 negative or positive patients.
The lack of national support for long-term care facilities during the pandemic has been “very concerning,” said Lori Smetanka, JD, executive director of the advocacy group National Consumer Voice for Quality Long-Term Care. “Every day we hear about the critical needs for protective personal equipment for staff, for testing for residents, and until those things are prioritized for long-term care facilities, I think we’re not at the point where we’re going to see this getting under control.”
However, the industry’s deficiencies have also played a role in nursing home outbreaks, Smetanka said in an interview. “We think that there has not been enough of an effort to hold facilities accountable for having proper protocols in place to stem the spread of infection within the facilities,” she said of the historical oversight process.
At the Life Care Center nursing home in Kirkland, Washington, ground zero for the US outbreak, federal and state inspectors found 3 “Immediate Jeopardy” situations in which patient safety was in imminent danger, including a failure to rapidly identify and manage residents who were sick.
A reckoning will come in the months and years ahead, as researchers analyze patterns among nursing home outbreaks. The Hartford Foundation and other groups are funding a National Academy of Medicine study on nursing home safety and quality, which Fulmer said is long overdue. The CMS has also announced the formation of an independent Coronavirus Commission on Safety and Quality in Nursing Homes. New CMS enforcement actions include increased fines for homes with persistent infection control violations, and the agency will now require states to perform on-site surveys of homes with previous or new COVID-19 cases.
“We have to get to the root and the heart of the problem so that we can figure out why some places had such deadly outcomes and others have been able to manage a little better,” Fulmer said. The proportion of deaths related to nursing homes “is shocking,” she added.
Nursing homes with a 1-star quality rating were more likely to have large COVID-19 outbreaks than those with 5 stars, according to a preliminary CMS analysis. But star ratings don’t appear to be the whole story behind the outbreaks. “What we’re finding is that certainly you can have homes that have had deficiencies…that are being hit, but there can be some very, very good homes that are doing just about everything right and the virus comes in and it’s very hard to contain,” AGS President Annette Medina-Walpole, MD, said in an interview.
Among the many realities, many nursing home residents are living with some form of dementia or cognitive decline that makes enforcing mitigation strategies like mask wearing and social distancing a major challenge.
Testing’s Toll
The new CMS framework recommends that nursing homes should be among the last to reopen in a community, allowing visitors only when there have been no new facility-onset cases for 28 days. Nursing home leaders agreed that a cautious approach to relaxing restrictions is prudent.
But experts said the CMS plan requires a testing capacity that is far from current reality. The guidance recommends baseline testing for all nursing home staff and residents, followed by ongoing weekly testing for staff, the primary source of new infections. All residents should be retested if anyone develops COVID-19 symptoms or tests positive for the virus. And nursing homes should have the capacity to retest every resident weekly until all test negative.
Although test availability for nursing homes has improved, some facilities still report shortages. “We hear from our members throughout the country that there are states that do not have access to testing,” Janine Finck-Boyle, MBA, LeadingAge’s vice president of regulatory affairs, said in an interview. Universal testing in nursing homes could tax the current supply, creating a new shortage of tests for symptomatic people throughout the health care system.
Laboratory capacity is another major concern. As testing increased recently, both state health department and commercial labs’ turnaround time for results has gone from 24 to 48 hours to as many as 5 days, said Richard Feifer, MD, MPH, chief medical officer for Genesis HealthCare, which operates nursing homes and senior living communities in 26 states. Some facilities have had to send their tests to different states because no laboratories in their vicinity can handle them, Finck-Boyle said.
The costs, too, are daunting, and nursing homes’ decreased revenue during the pandemic makes them only more challenging. The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) estimates that testing all nursing home staff and residents just once will cost $450 million. Testing assisted living staff and residents would add nearly $230 million more to the price tag.
Medicare covers at least some costs for certain residents, according to the AHCA/NCAL. But private laboratories often do not bill Medicare directly and require that long-term care providers pay upfront. “This creates a real burden for providers,” an AHCA/NCAL spokesperson said in an email. Testing costs for health care workers are another major looming question. According to AMDA, many nursing home staff can’t afford health insurance. For those who can, their tests may not be fully covered.
In Feifer’s view, CMS’s plan for reopening nursing homes is reasonable in its caution. “But I think it’s also fair to say that few, if any, nursing homes in America are ready to proceed down this path just yet,” he said in an interview. While he and others said they welcome guidance, they warned that states that adopt the recommendations without supporting their implementation could put an untenable strain on nursing homes that were stretched thin even before the pandemic began.
Already, more than a fifth of states had issued varying COVID-19 testing mandates in nursing homes by mid-May, according to Laxton, who said trained staff like the National Guard should carry out required testing. In at least 16 states, nursing homes or other long-term care facilities have received National Guard support as part of the COVID-19 response, according to a spokesperson for the military reserve force.
Considering the substantial barriers, not everyone believes universal testing is the best strategy. AMDA advocates for individualized testing plans that consider regional disease prevalence and local testing accessibility and capacity. For nursing homes in areas with low COVID-19 cases in the community, random testing combined with strict clinical screenings might be appropriate.
Dumyati, who works with nursing homes in the Rochester region, said she suspects that many staff will be reluctant to undergo uncomfortable testing every week and that some might decide to quit. “I don’t disagree that testing is valuable, but a more targeted approach might suffice,” she said in an email. That approach could prioritize testing for staff and residents in affected units or for staff that had contact with other COVID-19-positive staff or residents, similar to contact tracing in the community.
Short-Staffed
As testing ramps up, preexisting personnel shortages could be exacerbated if large numbers of certified nursing assistants (CNAs) and other staff test positive and must be quarantined. “We’re hearing very, very critical staffing shortages that are occurring right now,” Smetanka said. “We have serious concerns about what’s happening with a number of residents across the country.”
Some workers have fallen ill, while others have had to stay home due to a lack of childcare. Some are unwilling to show up for a demanding job that pays little and provides inadequate PPE and testing. It’s also expected that more workers will contract the illness as communities reopen, and more nursing home outbreaks are likely to follow.
Meanwhile, there’s more work to be done. Cohorting COVID-19 positive and negative residents in different areas means that staff must move the entire contents of their rooms, including furniture and other belongings. Staff must also source infection-control supplies, report cases and deaths to public health officials, communicate frequently with residents’ family members, and facilitate residents’ phone calls and video chats during the lockdown.
The work doesn’t end there. “Licensed nursing assistants are doing more than just helping somebody to dress and bathe and have their meal,” Christina Beauregard, the social services director in a skilled nursing and rehabilitation center in Hanover, New Hampshire, said in an interview.
Not long after regulators ordered an end to communal meals and family visits, some residents felt a keen sense of isolation. In the breach, Beauregard said, licensed nursing assistants “really stepped up to being the friend and the companion and the family member that the residents need to not feel lonely.”
Even so, staff encountered increasing depression among residents, some of whom had stopped eating and getting out of bed. Failure to thrive was on the uptick. “We have to keep people out to keep our residents safe, but it’s at a pretty costly price,” said Medina-Walpole, who has practiced in the long-term care environment for more than 2 decades. Advocacy groups like the Consumer Voice also expressed concerns about reduced inspections during the pandemic and the possibility of elder abuse going unchecked without family visits.
Although some large chains like Genesis have their own staffing companies to fill personnel openings, other homes may need more help. The AHCA/NCAL is asking governors to proactively recruit, train, and deploy additional workers for long-term care facilities.
The groups have floated solutions like relaxing state regulations to allow nurses and other health care workers to cross state lines and calling on the Medical Reserve Corps and the US Public Health Service to volunteer in nursing homes. State authorities could encourage people who are unemployed to sign up for temporary nurse aide and feeding assistant training courses and match them with long-term care facilities.
The groups say states must also do more to support and safeguard existing nursing home workers, and the ideas go beyond providing PPE. As communities reopen and the risk of infection increases, state and local governments could partner with food banks and restaurants to help workers buy groceries and meals without mingling with the general public, for example.
And while attention has been focused on hospital workers’ emotional needs during the pandemic, nursing home staff have at least an equal mental health burden. “There are infection preventionists in tears, staff that have to work 12-hour shifts nonstop, medical directors that haven’t had a day off since the beginning of April,” Dumyati said. “The stress that the health care personnel are going through, from medical director to the CNA, is unbelievable.”
In the coming weeks and months, she said, staff in nursing homes and other long-term care settings with deadly outbreaks will need help dealing with the trauma of losing beloved residents whom they’ve known for years. “In 2 days, they’re dead,” she said. “It’s awful.”
