Safe Staffing in Rhode Island

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Nursing home lobbyists are trying to trick Rhode Island legislators and citizens that requiring safe staffing at nursing homes will cause the world to collapse and everyone will go bankrupt.  Ridiculous.  Plenty of nursing homes provide staffing higher than what Rhode Island is suggesting as a minimum standard.

The proposed legislation would raise the state’s minimum staffing requirements. The minimum staffing legislation, sponsored by Rep. Scott Slater, requires nursing homes to provide 4.1 hours of direct care daily to each resident. Numerous article have made it clear that 4.1 is the minimum safe staffing for nursing home residents. It would also increase staff pay to a living wage at $15 per hour.

Scott Fraser, president of the Rhode Island Health Care Association, complained without evidence that the minimum safe staffing bill is “unrealistic” and would put many of the state’s nursing homes out of business. “There is no way homes can comply with the provisions of this bill and stay in business. It really is that simple.”

Right now, Rhode Island nursing homes provide an average of 3.6 hours of direct care to each resident, according to the U.S. Centers for Medicare and Medicaid Services. Attorney General Peter Neronha is among those who support the legislation, arguing that Rhode Island “is one of only a handful of states not to have a nursing home staffing standard.”

“Consequently, our state ranks near the bottom of the national average for hours of care provided to nursing home residents,” Neronha testified. “Many falls, infections and other injuries can be prevented by ensuring that health care workers are spending the time we know nursing home residents need to be safe and well cared for.”

History Repeating Itself

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The Atlantic had a great article explaining how America is back to making the same mistakes we made in March when we ignored science and the warnings of experts on how to stop the spread of coronavirus. Nursing homes were ill-equipped, both literally and figuratively, to deal with the pandemic, and federal and state governments took a hands-off approach until it was too late. The lack of government leadership and coordination has led to poor and delayed data collection on deaths and infections in nursing homes. CMS did not even require facilities to report coronavirus infections and deaths that occurred prior to May 8, even though the first nursing-home outbreak began in February.

The article mentions Melvin Hector, a geriatrician in Tucson, Arizona, who went into Sapphire of Tucson Nursing and Rehabilitation and found his patient in her room, wearing a surgical mask. She had been tested for COVID-19, but the results had not yet come back. When Hector asked for a mask for himself, he says a nurse responded, “We don’t have any.”

“I say to her, ‘You’re going into the room; the other staff are going in the room. She just went out to the hospital for a respiratory disease. And we don’t have any masks in the building?’” Hector recalled in a recent interview.

“They’re on order,” Hector remembered the nurse replying.

Sapphire ended their working relationship after Hector reported the situation to the Arizona Department of Health Services. Sapphire claimed that it had never suffered shortages of personal protective equipment, or PPE. In response to Sapphire’s statement, Hector said, “They lie.”

To Hector, the episode was a microcosm of the reasons why the United States has suffered so many COVID-19 deaths among nursing-home staff and residents. “Arizona is just one manifestation of a nationwide policy, an administrative policy to ignore this pandemic until it couldn’t be ignored,” Hector told me.

More COVID-19 deaths in nursing homes are likely, and they will have been preventable. American nursing homes are chronically short-staffed and, even prior to the pandemic, were doing a poor job of controlling infections. A Government Accountability Office report published in May found that more than 80 percent of nursing homes were cited for infection-prevention deficiencies from 2013 to 2017. About half of those homes had “persistent problems and were cited across multiple years.”

Adding to the challenge is that it’s not clear whose problem the nursing-home shortcomings are. Considering CMS is tasked with nursing-home safety, if the agency doesn’t “have enough resources, they should be going to Congress and demanding those resources,” Andy Slavitt, the former acting administrator of CMS under President Barack Obama, told me.

In response to a request for comment, CMS said that although the agency does oversee facilities, nursing homes are themselves responsible for the health of residents and should work with state governments to procure PPE. Authorities kept these facilities strapped for masks, tests, and other desperately needed equipment. The tragedy of even more nursing-home deaths will be worsened by the fact that they could have been stopped. Nursing-home covid-19 deaths may seem inevitable but according to interviews with dozens of nursing-home experts, it didn’t have to be this way. For example, some nursing homes in this country and other places have remained coronavirus-free.

Many nursing homes have likewise succeeded at keeping out the coronavirus. The Maryland Baptist Aged Home, a facility in Baltimore, avoided having any coronavirus cases. Its director, Derrick DeWitt, told me that in February, when the U.S. had just 15 known cases, he paused family visits and community meals, sent vendors and delivery drivers to a separate entrance, and brought in extra cleaning crews. The staff was trained on social distancing, screened regularly for their temperature and symptoms, and asked about their social activities. DeWitt, following the guidance of Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, and New York Governor Andrew Cuomo, said he ordered extra masks early, before they began to run out.

The federal government and nursing home industry could have learned from their previous failures on nursing homes. As COVID-19 ravaged care facilities along the East Coast all spring, officials in southern states, where infections are currently spiking, had months to prepare but they wasted that precious time seeking bailouts and immunity instead.

The Expendables

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The Washington Post had a great article about the fear and danger nursing home caregivers are experiencing because corporate management refuses to provide proper PPE, staffing, and training to prevent the spread of the coronavirus. More than five months into the pandemic, nursing home caregivers say they have been left to fend for themselves even as outbreaks continue to overwhelm facilities across the country. Tens of thousands of nursing home workers have contracted the coronavirus and at least 600 have died.

“There’s been a lot of talk about essential workers,” said Rob Baril, president of Service Employees International Union 1199NE, which represents nursing home workers in Connecticut and Rhode Island. “They’re treated like they’re expendable workers.”

Lawmakers, industry groups and caregivers say the death count could have been limited if the industry had done more to develop an early, robust and coordinated response for nursing homes and other long-term-care facilities. More than 2,200 nursing homes reported earlier this month that they lacked an adequate number of nurses, and 2,600 reported a shortage of nursing aides, according to the CMS.

Even with sufficient supplies, experts say, years of understaffing and cost-cutting have left nursing homes vulnerable to widespread infection outbreaks. Staff turnover is particularly high among nursing aides, who often earn minimum wage and lack paid sick leave or health insurance, said Charlene Harrington, a nursing home researcher and professor at the University of California at San Francisco.

“They don’t care if they burn through staff,” she said.

Government inspections found multiple instances where nursing staffs were stretched so thin, they did not have enough time to follow proper hygiene practices, such as washing hands in between patients. To address potential staffing shortages, the CMS in March waived the requirement that nursing aides receive at least 75 hours of training. The move, advocates say, could exacerbate unsafe conditions by allowing homes to employ unqualified staff members.

AARP’s 5 Point Plan

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Officials with the AARP are seeking changes in how nursing homes deal with the coronavirus pandemic.

The country’s largest organization representing elderly Americans is pushing a five-point plan that it says is necessary to better protect residents of long-term care facilities. Included in the requests are more stringent policies within the facilities, as well as more funding from the government to implement necessary changes.

The plan asks for improvements in staffing, transparency, and access to PPE and testing. It also seeks avenues through which families and friends of residents can set up virtual visits in the event that it is unsafe to visit in person.

Charles Williams, the head of the Kentucky AARP Executive Council, said that it’s important for such visits to be possible in order to promote transparency, as well as to allow residents to see familiar faces – something that can improve mental and emotional health.

“When we can see our loved ones, we know what their status is, what is going on with them, and what kind of care they’re getting,” he said. “And we can also discuss their situations with the staff. So if we cannot have these visitation rights because of COVID-19 and isolation, we think that through virtual visitations, we will still be able to see our loved ones.

Williams added that lawmakers can help facilitate the action sought by the AARP by appropriating more funding to the sector. Another way the legislative branch can play a role, he said, is by rejecting any proposals that would shield nursing homes from lawsuits related to COVID-19.

Trump Wears a Mask!

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The number of new daily coronavirus cases in the United States topped 60,000 for the first time on Friday. Recorded cases are now on the rise in 37 states, prompting state governments to re-evaluate plans to reopen their economies. The country is now averaging roughly 750 deaths from the virus each day.  South Carolina is surging and still re-opening for some reason.

Florida announced 15,000 new cases of the virus yesterday, the highest single-day total of known infections for any state thus far.  Governor Disaster is incompetent and defensive.

In order for us to reverse this problem, we need about 90 percent of people in those really hot areas to wear masks when they’re in public. Republicans in the Senate have refused to take up the $3 trillion relief bill that House Democrats passed in May.

Gerontocracy

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Mark Harris had a great article for The Cut about the power and vulnerability of elderly people right now. Below are excerpts.

Each day’s headlines jolt us with the same unnerving reality: There has never, in the history of the Republic, been a stranger time to be old. We live in a kind of gerontocracy that feels both accidental and deeply entrenched.

The futures of all Americans are largely in the hands of people who are entering, or well into, what one of my uncles used to call “the bonus round.” And yet the aged, at the height of their power and disinclined to relax their grip on it — just look at who votes — have also never been more vulnerable.

Almost 60 percent of those who have died from COVID-19 in the U.S. were 75 or older. Almost 80 percent were age 65 or older. Residents of nursing homes or assisted-living facilities have made up as many as half the fatalities in some areas of the country, and the reaction among many people, either by implication or outright declaration, has been, “See? That means most of us have nothing to worry about!”

This virus continues to rob old people of their futures — futures they are as entitled to invest with hope and energy as anyone else. Because the elderly are both a hardy and a precarious population — one that is depleted every day even as it welcomes new members to its ranks — it has become easy for some people to treat them as both more and less than human; they’re either a population of noble Yodas we can mine for every nugget of gnomic sagacity before we discard them, or they’re obstructions interposed between the idealistic and/or selfish and the things they respectively crave.

“They” are us, only with more miles, more wrinkles, more history, more joint pain, sometimes more money, often more knowledge, almost always more perspective. If we’re very fortunate, one day we will become them, even if, as a 98-year-old neighbor told me a few years ago on his way out for a short walk, “I know what you’re thinking. But believe me, it’s no picnic.”

“Deadly Delay”

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The Trump administration was slow to comprehend the scale of COVID-19’s impact on nursing homes and a confused, disjointed federal response only compounded the fatal toll, according to a Senate report. The report finds a lack of coordination among government agencies hindered access to coronavirus testing and protective equipment, among other problems.

“Unfortunately for the nation, it is a chronicle of deadly delay, and a lack of urgency, and the lack of a strategy,” said Sen. Bob Casey of Pennsylvania, ranking Democrat on the Aging Committee. “What we see in the way the administration handled this reflects the administration’s failure in responding to the pandemic generally.”

Investigative agencies like the Government Accountability Office and the Health and Human Services inspector general are also focusing on nursing homes, which house a tiny share of the population but represent a large proportion of COVID deaths.

Even now, four months after the first nursing home outbreak was reported in Kirkland, Washington, on Feb. 29, there’s no consensus estimate of the extent of suffering and death. Urgent recommendations from the White House and guidance from CMS to test nursing home residents and staff did not translate to results on the ground because there was no system in place to guarantee the availability of tests and supplies.

The nursing home industry has been cited for poor infection control practices and chronic staffing shortages to blame for not being prepared. Staff members often work at multiple facilities and may have unwittingly contributed to spreading the virus, since people can be contagious without any noticeable symptoms.

Investigating Nursing Homes

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Kellie Schmitt wrote an interesting article for Center of Health Journalism about how two top journalists explained how to research and investigate nursing homes during the pandemic in a webinar called “Covering Coronavirus”.

Charles Ornstein, deputy managing editor at ProPublica, described the devastating and disproportionate toll taken by coronavirus on the country’s nursing homes, and how reporters can better understand, quantify and report on the crisis in their own communities. He was joined by fellow journalist Chris Kirkham, an enterprise reporter at Reuters, who offered a behind-the-scenes look at his own investigation into longstanding staffing shortages that left these facilities especially vulnerable to COVID-19.

Nursing homes had challenges even before the pandemic struck including 82% of nursing homes surveyed from 2013-2017 were cited for infection prevention and control deficiencies.

“This is a perennial problem and our coverage of the issue today needs to have that context of where we’ve been in the past,” he said.

When COVID-19 hit, nursing homes did not have the testing capabilities or the personal protective gear for staff they needed. Other challenges include low-paid staff who often need to work multiple jobs, and a history of deficiencies, particularly for infection control, he said.

The federal government’s searchable database on nursing homes and COVID-19 has been “deeply problematic,” and plagued with inaccuracies and inconsistencies, Ornstein said. As the pandemic has progressed, that information has improved, but it still doesn’t always line up with the information provided on state web sites.

“You need to be really careful about using this data without looking up as much as you possibly can and asking tough questions,” he said.

Ornstein also suggested telling the story of a nursing home in your community that kept COVID-19 at bay or one that got particularly slammed by the virus, and compiled this tip sheet for reporters covering the nursing home story.

Reuters reporter Chris Kirkham, who wrote a special report on nursing home staffing shortages with Benjamin Lesser, was initially interested in figuring out whether nursing homes with COVID-19 outbreaks had histories of deficiencies. But the reporters struggled with the spotty federal and state data.

They also wanted to report on something systemic, so they turned their focus to staffing. They heard from a lot of overworked workers who said staffing had always been a problem, but COVID-19 “has really just blown a hole into that entire system.” While management was publicly calling these workers “heroes,” many insiders did not feel they weren’t getting adequate support, he said.

To get a sense of the staffing situation at nursing homes coming into COVID-19, Kirkham and data journalist Lesser conducted their own analysis to grade staffing. They decided to use California’s minimum staffing requirements as a benchmark since its standards is among the highest and had been recently updated. They calculated that 37% of nursing homes throughout the country would not have met the minimum staffing requirement in California. And, at least 70% of the homes would not meet the higher bar that some experts recommend.

When two nurses who had gone on record about the “nursing home nightmare” faced retaliation,  Kirkham wrote a follow up story and quoted the Massachusetts attorney general.

Those fears of retaliation might scare sources into not talking on the record, a risk that means reporters should approach these situations carefully, he said. Even if someone doesn’t want to be interviewed on the record, listen to their story anyway and stay in touch, as their circumstances may change.

Kirkham emphasized the importance of determination and persistence when searching for on-the-ground voices. For his project, he created a spreadsheet with about 250 names and ended up connecting with 5% to 10% of them.