McKnight’s had another article showing the nursing home industry begging for more tests to keep residents and caregivers safe.  Asymptomatic carriers, or “silent shedders,” are responsible for much of the introduction of the novel coronavirus in nursing homes, said Vince Mor, Ph.D., a Brown University researcher with decades of experience. He currently is analyzing outbreaks and prevalence among Genesis HealthCare facilities.  COVID-19’s ability to hide in plain sight will continue to crush expectations of halting its spread unless more and quicker testing at nursing homes sweeps the country.

“There are lots of documented cases where people are shedding virus asymptomatically for four or five days before they become symptomatic. And in many cases, the younger people never become symptomatic,” Mor told attendees at an Alliance for Health Policy webinar on Friday.

Further, he said there is “lots” of anecdotal evidence suggesting positive cases in nursing homes that then become no longer positive, “just like a teenager: They get the disease, it didn’t affect them and then it went on, but they were shedding virus in that time. They were a silent shedder in that sense. The only hope we have is for testing.”

Genesis Chief Medical Officer Richard Feifer, M.D., confirmed that about half of all COVID-19 cases are asymptomatic, and the case fatality rate is about 20%. While test turnaround times have improved from as long as 11 days to 24 to 48 hours, Feifer added, supplies and services are still woefully lacking. That could lead to quicker and more efficient cohorting, experts point out. Instead, nursing home residents — and workers especially — are left to often unwittingly share the virus, sometimes at multiple facilities.

“Swabs and testing are still inadequate in many states,” he said. “What we really need urgently is point-of-care rapid testing. For the virus, not the antibody.”

 

Since the global pandemic erupted in March, the Centers for Medicare & Medicaid Services (CMS) through State surveyors have only inspected about 6,800 nursing homes, or 44% of the nation’s total.  This was a weak effort by CMS after the coronavirus was unleashed to insure that nursing home caregivers had the proper training and supplies for safe infection control going forward.  Guess what?  It didn’t work.

Three major areas of “sporadic noncompliance” still remain among nursing homes that were inspected: hand hygiene, proper use of personal protective equipment (PPE), and cohorting.  They just happen to be the three most important infection control prevention techniques.  

PPE violations were related to improper use — including incorrectly donning and doffing masks and gowns.  Nursing homes and other long-term-care facilities have been the hardest-hit by the virus, with more than 150,000 cases and 30,000 deaths linked to Covid-19,

Meanwhile, the Trump Administration is developing guidelines for reopening nursing homes even proposing steps that would allow visitors to return to facilities that have been hit hard by the coronavirus pandemic despite lockdowns. The capability to conduct frequent, broad testing is crucial, industry officials and infection-control experts said.  Experts warn that moving too fast will increase the risks for frail and elderly residents, who have been dying in the tens of thousands due to the virus.

 

 

McKnight’s recently had an article where a nursing  home defense legal expert is offering advice to protect nursing homes from being held responsible for any neglect or negligence during the pandemic.  Advocates and experts recommend that providers document everything related to their response to the coronavirus pandemic. It’s a move that could help providers defend themselves in a potential lawsuit stemming from their response.  Of course, that is already the standard.  Facilities should be making complete, accurate, and timely documentation of all care and treatment provided to residents.  Often nursing homes will not document and then argue they chart by exception or only when something is wrong. In addition, the Florida Health Care Association came under fire over the weekend, when the group had written the governor to ask for blanket immunity for healthcare providers from COVID-related lawsuits.

“Documentation is critical. Document, document, document your efforts,” Christy Tosh Crider, chair of Baker Donelson’s Health Care Litigation Group and the Women’s Initiative. She issued the warning during a webinar hosted by the Society for Healthcare Organization Purchasing Professionals (SHOPP).  “You need to be documenting as each new piece of guidance comes out. As you and your organization respond to that new piece of guidance, document what you knew, when you knew it and what your response was,” she advised.

Many providers may be subject to lawsuits in the coming months due to unfortunate patient outcomes from the new coronavirus, she assumes, adding that supply managers and procurement officers may become critical witnesses in such litigation.  Tosh Crider said the focus of future lawsuits likely will involve staff members who have tested positive for the disease returning to work; struggles to get personal protective equipment; and staff training on how to effectively use personal protective equipment. For procurement officers at the corporate level, she warned that they should be documenting all of their decision-making and struggles regarding PPE.

“Every piece of that you should treat as if it will have to be turned over some day in litigation. Treat your documentation as if I’m going to have to deal with it during an opening statement to a jury,” Crider said.

“Treat it as if you’re going to have to turn it over to a regulatory body, and ask yourself is this communication sending the right message about our organization’s commitment to put proper PPE in place for the protection of our residents and the protection of our frontline caregivers,” she added.

Skilled Nursing News reported that problems with planning, budgeting, and securing sufficient quantities of personal protective equipment (PPE) to prevent or contain infections and viruses but in the skilled nursing setting, many providers are  struggling because of poor planning, inadequate budgets and capitalization, and severe shortages — even as they try to contain a contagious disease that presents known dangers to their patient population. Widespread shortages of masks and gowns, coupled with a lack of quick and accurate testing kits, have prevented many operators’ efforts to prevent the spread of COVID-19 in nursing facilities.

To avoid getting blindsided by legal actions emerging from the COVID-19 emergency, Crider emphasized that SNFs need to document every step they take in providing care. This is going be particularly important because family members are currently not allowed to visit their loved ones, and will not see the care provided firsthand, she said on the webinar.

Plaintiff’s attorneys are already talking about staff who tested positive for COVID-19 and returned to work, operators that continued to admit new patients — especially in the long-term care setting — after a positive diagnosis in the community, and struggles to obtain PPE. That last one is a particularly important point.

“That is being quoted in almost every interview with plaintiff’s attorneys, is the issue of PPE,” Crider said.  That makes it all the more important that providers capture their decisions around PPE in writing, especially when it comes to the allocation of supplies to given facilities, she said.

In particular, it’s crucial for SNFs to know how much PPE they’re using, as Melissa Powell, the chief operating officer at the Allure Group in New York, emphasized on the webinar. It’s not just a matter of knowing what PPE is required — especially since most SNFs are ordering items they haven’t had to use before — but also knowing when to order it, she explained.  That means knowing the daily burn rate at a facility, knowing how to calculate it, and how that rate will change if a patient comes back positive. And SNFs have to be sure their suppliers are in the loop, and be sure they know what is going out of stock.

She also emphasized the need to stay on top of guidance around PPE, despite the challenges of keeping up with the information coming out of state and federal governments.

 

Harvard epidemiologist is warning that nursing homes are no longer the best place to house vulnerable elderly patients.  Michael Mina, an assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health and its Center for Communicable Disease Dynamics, said that he believes the coronavirus that causes COVID-19 is more transmissible than previously thought. It has been difficult to keep it from spreading in a number of settings, including hospitals, cruise ships, and nursing homes.  Even with current restrictions on visitors, he said, employees regularly moving in and out of the facilities means it’s likely that additional cases will occur.

“I do think as many people as we can get out of these homes, [it] is probably better,” said Mina, also a Chan School associate professor of immunology and infectious diseases and associate medical director in clinical microbiology at Brigham and Women’s Hospital’s Pathology Department. “I think that this is an extraordinarily transmissible virus. I think it’s more transmissible than we recognize and actually preventing it from spreading within nursing homes is an extraordinary feat.”

Mina said he recognized that some nursing home residents don’t have acceptable alternative living arrangements. Absent relocation, he advocated giving the facilities resources for stepped-up surveillance, such as testing employees every few days to keep the virus from entering and nipping in the bud any outbreaks that do occur.

A virus that has already spread widely in the population requires a different response than one whose spread involves the cases already found through current testing, Mina said. If the virus has already infected many more people than testing to date has shown, that would mean that the very serious cases in hospitals today are a small portion of the total number, and that pouring resources into contact tracing might not be the best policy. If millions of people have already been infected and recovered, that would mean that the population is on the path to herd immunity — the threshold at which the level of immunity in a population naturally inhibits further transmission.

On the other hand, he said, if the current testing has captured somewhere close to the true number of cases, that would mean the virus is more virulent, with a significant proportion of cases becoming serious. It also means that efforts to suppress the virus through contact tracing are important.

“We still don’t know if this virus has infected say, 300,000 Americans or 15 million Americans,” Mina said. “And, until we really understand that difference, it’s very, very difficult to know how many people we need to be testing.”

Mina said recognition of the need for serological testing problem is widespread in the scientific community and a variety of companies are at work on them. The tests will likely take different forms, from those that must be administered in a doctor’s office to something like modern pregnancy tests that could be sold in packs at the local pharmacy and used at home.

“We have to get to an order-of-magnitude-understanding of how many people have actually been infected,” Mina said. “We really don’t know if we’ve been 10 times off or 100 times off in terms of the cases. Personally, I lean more toward the 50 to 100 times off, and that we’ve actually had much wider spread of this virus than testing … numbers are giving us at the moment.”

Nursing homes are used to cutting corners and doing the bare minimum to increase profits.  With COVID-19, the facilities are having a hard time exploiting the situation.  Updated guidelines on the use of personal protective equipment (PPE) are causing associated financial pressures, even though the facilities are always supposed to be prepared to prevent and contain infections and viruses.  In mid-March, the American Health Care Association (AHCA) predicted that 20% of nursing homes in the U.S. would run out of masks and gowns in a week’s time. Now, at the beginning of April, providers across the country are struggling to keep enough PPE In stock for their staff.

The federal government expanded use of PPE, with the Centers for Medicare & Medicaid Services (CMS) calling for the blanket use of face masks as long as an emergency declaration was in effect — as well as full PPE in all buildings with evidence of COVID-19 transmission.

For the average 100-bed SNF, following these new guidelines in the long-term care setting would lead to increased costs of $10,000 per day as staff follow the directive to “wear full PPE for the care of all residents irrespective of COVID-19 diagnosis or symptoms,” according to an analysis announced by the Society for Healthcare Organization Procurement Professionals (SHOPP) by Michael Greenfield, the CEO of Prime Source Healthcare Solutions and one of the cofounders of SHOPP, and Faygee Morgenshtern of People Powered Nursing. Greenfield broke it down in terms of the equipment an average facility with a census of 100 would need, should it have “one active COVID patient.”  According to Greenfield, the minimum amount of PPE items per day would be:

  • 100 N95 facemasks (reusable)
  • 100 gowns x 100
  • 200 gloves x 100
  • 100 face shields (reusable)
  • 100 8-ounce hand sanitizers x 3

The biggest challenge now is the same challenge for the caregivers before the pandemic: they don’t have funds, they don’t have the support, they don’t have the training, and they don’t have the supplies. Of course, the challenge is that product arriving in two weeks’ time does not help a facility that has an outbreak in that interval — and outbreaks in nursing homes in the U.S. have been growing by the day.  In the meantime, providers are still paying significantly more for PPE than they ever have in the past. Though the number fluctuates from day to day depending on market demand, some operators told SHOPP that they used to only spend between $20,000 to $25,000 per year on PPE items.

In addition to the PPE expenses, staffing poses a significant concern, particularly amid new CMS guidance requiring operators to assign specific staff members to groups of residents. If a facility has a 1:10 staffing ratio of nurse to patients, and four patients arrive with a diagnosis of COVID-19, then one nurse cannot take care of four COVID-19 patients and six patients without the virus. That means staffing ratios have to change, which in turn means having to creatively use the layout of a given building.

 

Because of inadequate staffing, lack of personal protective equipment, and poor infection control procedures, the coronavirus is spreading through the nation’s nursing homes.  Over the past month, coronavirus infections at nursing homes have skyrocketed: More than 500 long-term care facilities around the United States now have infected residents, according to the Centers for Disease Control and Prevention — a 172 percent increase in a single week.

Industry apologists argue that nursing homes have been unable to get enough protective gear and tests because hospitals are getting the supplies first. Protective gear is especially critical in nursing homes since many residents have physical limitations or dementia that prevent them from being able to cover their mouths when they cough, or from wearing a mask themselves.  Families are worried about their loved ones especially when they can’t visit the facility, and the nursing homes prohibit video conferencing and other video communications.  There is no way to check on your loved ones. The Centers for Medicare and Medicaid Services requires nursing homes to notify family members if their relative has a confirmed coronavirus infection, but not if others in the facility have tested positive.

ArchCare is telling people to take their loved ones home.  They are admitting they can’t keep them safe.  ArchCare has been forced to outfit staff members in rain ponchos and beautician gowns to stretch their dwindling supply of protective gear, according to Scott LaRue, president and CEO of the company.

More than 200 of ArchCare’s 1,700 nursing home residents are infected with the coronavirus, and more than 20 have died, LaRue said. At least 10 staff members are also infected, with one in the hospital on a ventilator.

The risks are so serious that LaRue is advising family members to pull residents out if feasible. “If you have the ability to take your loved one home, and that’s possible, I would encourage you to do so,” he said. “There will be better isolation and better limited contact in a home than there would be in a nursing home.”  However, LaRue acknowledges that the medical and personal needs of most residents are too complex to handle at home.

The ArchCare aide said that staff members are only being given one disposable gown for their entire shift, even if it becomes soiled, and they must constantly circulate between residents who are infected and those who are not.

“How do you expect to use the same gown? We are cleaning them, wiping their mouths, there’s stuff on us,” the aide said. “I feel like I’m spreading the virus.”

While one area of the nursing home where she works had once been designated for infected residents, there are now so many who are sick that they are mixed in throughout the entire facility, the aide added.

In Washington state, which reported the first coronavirus cases in the U.S., 35 people died after an outbreak at the Life Care Center of Kirkland, a skilled nursing facility. A CDC report found that a lack of personal protective equipment and staff members who continued to work while sick helped fuel the deadly outbreak, which quickly spread to other nursing homes in the area.

Similar cases have exploded across the country. At one facility in Stafford, Connecticut, three residents have died and at least six employees are now infected, with staff reporting a lack of protective gear and limited testing. At two nursing homes in southwest Pennsylvania, infections are growing among both residents and staff, who say they don’t have enough masks to protect themselves. In Louisiana, where 13 residents have died in a single nursing home, one 130-bed nursing home reported having no personal protective gear at all.

We’re in a situation where it is impossible for us to stop the spread of the virus,” LaRue said. “They say this is our highest-risk population — the one we have to protect the most — and they’re not giving us what we need to do that.”

Supplies have been scarce on all levels of government but Trump refuses to use his power to coordinate production and distribution.  Trump has narrowly limited its use of the law and continues to tell states to try to buy the supplies themselves from private vendors. But the demand for masks, gowns, face shields and other equipment has created chaos as states, hospitals, nursing homes and other facilities are all competing to purchase the same critically needed supplies.

Nursing homes are also facing a lack of testing, which makes it even harder for them to contain the virus. Testing at nursing homes remains highly limited because of a shortage of swabs and other components needed to conduct the tests, as well as restrictive state guidelines.

That has made it impossible to identify and isolate all the residents who are infected from those who are not, LaRue said. “If I had my druthers, I’d do widespread testing, and I would test every employee.”

The problem is widespread, according to the American Health Care Association: “We have heard from many providers about residents and staff getting declined when trying to be tested. This is extremely worrisome.”

Once again, Trump has waited too long to act.  Last week, the Trump administration issued a new set of “critical recommendations” to operators and their governing entities. “Nursing homes have become an accelerator for the virus,” the Centers for Medicare & Medicaid Services noted in a statement detailing the new guiding statements. “Hundreds of facilities across the country are experiencing increased numbers of cases among residents.”

The administration made clear that it wants every single person within a nursing home to have his or her temperature checked, and be screened for other possible signs of the novel coronavirus. Trump also said that COVID patients should have their own buildings or units, and dedicated staffing teams.

Another recommendation calls for all nursing home personnel to don a face mask “for the duration of the state of emergency in their State.”

Nursing homes are still not taking infection control intervention seriously. An initial wave of surveys this past month found that more than one-third (36%) of facilities still did not follow proper hand washing guidelines and one-fourth did not use personal protective equipment properly. The agency  is trying to protect the industry from accountability by announcing it had suspended all regular survey investigations.  The agency’s first recommendation simply stated, “Nursing homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control.”  “Both of these are longstanding infection control measures that all nursing homes are expected to follow per Federal regulation,” CMS officials said in a statement.

Any person in a nursing home, whether they’re staff, residents or visitors, must submit to a temperature check before being allowed in, the recommendations specify. And top management should supply appropriate PPE  to be used any time staff members interact with residents.

In addition, the administration formally called on facility managers to pursue consistent assignment of separate staffing teams (for infected and non-infected residents) “to the best of their ability.” As with recommendations regarding PPE, officials hedged on the firmness of their advice, tacit acknowledgement that providers should do their best in light of PPE and worker shortages in many places.

The Trump Administration will no longer allow federal investigators to oversee and supervise nursing homes. Federal regulators plan to halt inspections of nursing homes to focus on coronavirus cases in facilities across the nation. Unsafe practices, poor training, and inadequate staffing led to serious infractions at the hardest-hit location. Many nursing homes have long struggled with infection control, according to federal inspection records and researchers. They need oversight and inspections to maintain compliance with safe practices.

Under the changes, regular inspections of nursing homes, home health and hospice companies, will be paused for April. The number of abused and neglected residents will skyrocket in the next 30 days.  Especially since family and other visitors are prohibited from checking in with their loved ones.  The lack of oversight and inspection was made under the Trump administration’s declaration of a national emergency.

The move follows a recent inspection of the Life Care Center of Kirkland, a nursing home near Seattle, which is tied so far to 35 coronavirus deaths. CMS said the inspection found three major violations at the facility that put residents in imminent danger, including not quickly identifying and managing sick residents. Life Care said it had faced an unprecedented crisis and has fixed the issues.

 “Right now, the biggest threat to our nursing home residents is the coronavirus,” CMS Administrator Seema Verma said in an interview. “We cannot have a repeat situation like we had in Kirkland.”  However, she agency isn’t blocking one practice that the CDC said may have made several nursing homes in the Seattle area more vulnerable to the spreading outbreak: staff members who work at more than one nursing home.
Nursing homes house the population most vulnerable to the respiratory sickness: older, often frail residents with underlying medical conditions.  At least 146 nursing homes in 27 states have at least one infected resident, CMS said, citing data from the Centers for Disease Control and Prevention.

 

 

 

Nursing homes – including the Kirkland, Washington facility that’s been linked to 35 deaths – are vulnerable to the spread of the Covid-19 virus because staff members work while displaying symptoms, according to a report released by the U.S. Centers for Disease Control and Prevention.  Inadequate equipment and poor infection control play a role as well, as did failing to recognize an infection and change of condition, according to the agency’s “morbidity and mortality” report. The findings may shed light on how long-term care facilities should respond to infections that pose a threat to their residents.

In addition to symptomatic workers, the agency cited four other factors that “likely contributed to the vulnerability of these facilities”:

* staff members who worked in more than one facility;
* inadequate training and adherence to standard, droplet, and contact precautions and eye protection recommendations;
* challenges to implementing infection-control practices including inadequate supplies of personal protective equipment and items such as alcohol-based hand sanitizer;
* delayed recognition of cases because of low index of suspicion, limited testing availability, and difficulty identifying persons with Covid-19 based on signs and symptoms alone.

Long-term care advocates and infectious disease experts state that federal regulators and state inspectors have failed to hold nursing homes to safe standards of infection control – and often failed to exact meaningful penalties for violations.