EvSOP: COVID-19 in Long-Term Care: The Finger-Pointing Begins

By John Scherberger, FAHE, T-CSCT, VPEI

The U.S. first heard of COVID-19 being on our shores when the story broke about unknown respiratory events at the CMS five-star-rated Life Care Centers of America in Kirkland, Wash.  [For a link to a 60 Minutes segment: https://youtu.be/fPqHCcvP_cA] Keep in mind that the five-star rating is the highest awarded by the Centers for Medicare & Medicaid Services (CMS) to nursing homes.

CMS and state inspectors serve a genuine need to ensure that hospitals and nursing homes remain vigilant and responsive to the needs of the communities they serve. During times such as these, with COVID-19 returning to communities that thought they were ahead of the COVID-19 tsunami, only to find wave after wave battering their population, hospitals, and LTC facilities, one must ask a compassionate question: “When a facility is doing its best with the training, supplies and resources it has and without the resources it needs and have asked for, does it make sense to interfere with their efforts and send investigators to point fingers and impose hundreds of thousands of dollars in fines rather than sending the aid needed to provide treatment to those afflicted by the pandemic?” Nursing homes need government partners, not government predators during the ongoing tsunami of COVID-19. A good analogy is to ask why a fire inspector is finding fault with firefighters’ actions while the fire rages all around them.

The direct commitment of long-term care (LTC) professionals in nursing homes and other LTC facilities is to improve the quality of life of predominately older persons. Unfortunately, there are huge impediments that negate the commitment and negatively affect patients, residents, and staff.

Fortunately, there are success stories, but sadly, many of them go unreported.

Yes, there are stars to be found in the galaxy of nursing homes, but even with the telescope of investigations, the universe appears sparsely populated with five-star facilities.

One state attorney general (AG) who is involved in an ongoing investigation has released information that is not only unacceptable but outright abhorrent. Sadly, many of this AG’s findings are common among nursing homes in the U.S. Here are some of the highlights of that report:

  • A larger number of nursing home residents died from COVID-19 than Department of Health data reflected.
  • Lack of compliance with infection control protocols put residents at increased risk of harm.
  • Nursing homes that entered the pandemic with low CMS staffing ratings had higher COVID-19 fatality rates.
  • Insufficient personal protective equipment (PPE) for nursing home staff puts residents at increased risk of harm.
  • Insufficient COVID-19 testing for residents and staff in the early stages of the pandemic put residents at increased risk of harm.
  • The current state reimbursement model for nursing homes gives a financial incentive to owners of for-profit nursing homes to transfer funds to related parties (ultimately increasing their profit) instead of investing in higher staffing and PPE levels.
  • Lack of nursing home compliance with the state governor’s executive order requiring communication with family members caused avoidable pain and distress; and
  • Government guidance requiring the admission of COVID-19 patients into nursing homes may have put residents at increased risk of harm in some facilities. It may have obscured the data available to assess that risk.
  • The COVID-19 pandemic exposed many failings that were and continue to exist in nursing homes. Most shocking is a lack of compliance with infection prevention and control policies such as:
  • Failing to isolate residents who tested positive for COVID-19 properly.
  • Failing to adequately screen or test employees for COVID-19.
  • Demanding that sick employees continue to work and care for residents or face retaliation or termination.
  • Failing to screen staff members properly before allowing them to enter the facility to work with residents.
  • Failing to train employees in infection control protocols.
  • Failing to obtain, fit, and train caregivers with PPE.

Pre-existing medical conditions and morbidity may contribute to the number of deaths experienced in nursing homes in the U.S. but failing to train and equip staff adequately has been a direct contributor to COVID-19 deaths.

As of the end of January 2021, 39 percent of COVID-19 deaths have occurred in nursing homes. A new report from AARP revealed quicker actions could have prevented a great many deaths.

According to the report, CMS gave $21 billion in federal relief funds to nursing homes nationally, with only $2.5 billion allocated toward infection control, with the rest granted with “no strings attached,” the report said. Seventy percent of LTC facilities are for-profit, according to the report. And those for-profit facilities are linked to higher death rates. Where did the remaining $18.5 billion go?

AARP asked: “Who’s to blame for the 100,000+ COVID dead in long-term care?”

From the early days of the COVID-19 pandemic outbreak, finger-pointing has been widespread and blame placed at the feet of a single nursing home by federal and Washington state inspectors, but the causes were laid decades ago and not in Kirkland, Wash.

Who and what is at fault?

Outdated Laws

  • 1950s laws led to hospital-like settings for most nursing homes
  • 1960s laws ultimately made nursing homes reliant on government funding
  • Medicaid rules force many into nursing homes against their desires.
  • Government officials, both elected and career bureaucrats
  • Early pandemic decisions deprioritized nursing homes.
  • Months of limited testing let the virus go unchecked.
  • It wasn’t until September 2020 until wide-spread testing was recommended.
  • CMS directed nursing homes to ban visitors and nonessential personnel and restrict residents’ communal activities. It made no recommendation to do more rigorous testing for the virus.
  • As previously mentioned, nursing homes had received over $21 billion in federal relief funds, but only $2.5 billion specified for infection control; the rest came with almost no requirements for spending the funds.

Healthcare bureaucracy

  • Agencies, owners, governments all pointed to others to take charge, reminiscent of the proverbial “circular firing squad.”
  • CMS suspended routine state inspections. Some states directed that state inspections be not only stopped but required that inspectors not visit the facilities.
  • Still, nursing homes are very leery of accepting outside organizations’ assistance, fearing violation of non-disclosure agreements and fines levied.

With the recent change of administrations in Washington, D.C., some people are hoping (depending upon one’s political leanings) that policies that positively affected Nursing homes are retained and policies that hurt or hindered nursing homes removed.

  • With the new presidential administration comes an influx of life-long bureaucrats that have served in previous administrations that failed to improve the lot of nursing homes. What was it that Einstein said was the definition of insanity?
  • There is a difference between policies and politics, but elected officials and career bureaucrats have yet to learn the differences.

The nursing home industry

  • Many facilities were understaffed and underfunded before the pandemic.
  • The for-profit structure appears to have reduced intervention quality at many homes.
  • Facilities that had received lower quality ratings from regulators before the pandemic were more likely to suffer outbreaks.
  • The American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) is the largest in the United States, representing long term and post-acute care providers, with more than 14,000 member facilities.

As is customary, the blame game continues to be ongoing and well-funded. AHCA/NCAL are spending $15 million on a media campaign to change nursing homes’ public perception. They are also pushing states and the federal government to enact immunity from legal liability during the pandemic. Thus far, 20 states have provided such immunity. Where did the $15 million originate?

What exactly happens in nursing homes? The common misconception, or perhaps the word perception, is more appropriate, and funding has bought into this misconception that nursing homes are places older people go to live until they die. This misconception is so far from the truth, yet it is embraced by too many people, particularly those that have never personally visited a nursing home but control the purse strings. The truth is that nursing homes also provide specialized treatment and care as well as therapies for everything from Alzheimer’s and dementia treatment, to orthopedic rehabilitation, pain therapy, pulmonary disease, stroke recovery, physical therapy, occupational therapy, speech therapy and respiratory therapy.

What is not lost on nursing home professionals is that although COVID-19 is devastating to patients, families, and staff physically and mentally, they have the daily challenges of providing appropriate medical therapies and interventions directed by medical directors. The reality of multiple drug-resistant organisms (MDROs) is not going away. The fact is that where once an MDRO was a singular event in a patient, not these professionals must be prepared to pivot to SARS-CoV-2 surveillance in everyone and COVID-19 interventions when necessary.

They are doing these interventions with limited funds, reduced staffing, more surveillance from government, family, and multiple press outlets that are more interested in following their mandate of finding stories that fulfill their unspoken assignment of “if it bleeds, it leads.” They are interested in a story, not the people suffering both short-term and long-term. These bring us to a nexus of professionalism, money, and a shortage of training, equipment and supplies.