There are “significant deficiencies in infection control practices,” Seema Verma, administrator of the Centers for Medicare and Medicaid Services, told nursing home operators in a call Thursday. Her own agency has been criticized over lax enforcement and flawed record-keeping.
In Texas, the seven-day average of new nursing home cases nearly tripled in July, from 148 per day to 413 as of Aug. 6. By the beginning of August, 60 percent of all Texas nursing homes had at least one active coronavirus-positive case among staffers or residents. Both those figures have since declined somewhat as cases have plateaued but are still well above earlier levels.
The number of Florida residents living in nursing homes and assisted-living facilities testing positive doubled between July 7 and July 27 and has remained steady since. The seven-day average of new cases in California nursing homes has risen nearly 40 percent since the first week of July.
“I don’t think anybody’s doing a good job at this,” said Amanda Fredriksen, advocacy director at AARP Texas. “That doesn’t mean folks aren’t trying.”
Federal health agencies have been unable to foster mass production of rapid-result tests needed to reveal infections. State health department guidance has been limited and advisory when comprehensive and obligatory measures, including stepped-up inspections, could have made a difference, according to health-care advocates.
And nursing home owners have had months to prepare infection control measures since the devastation in the Northeast provided a vivid warning, and they have received up to several hundred thousand dollars each in emergency federal assistance.
In California, Texas, Oklahoma, Arizona and Florida, cases rose rapidly this summer among young adults. And health officials say that once community spread has taken hold, it is only a matter of time before the virus finds its way into nursing homes. That is true even as total cases in these states have started to recede.
“When there’s high community spread, the odds are not in your favor,” said Greg Shelley, program manager of the Harris County, Tex., Long-Term Care Ombudsman Program, which is at the Cizik School of Nursing at UTHealth.
“And once it gets in, it can be difficult to contain,” said Kristen Knapp, a spokeswoman for the Florida Health Care Association, which represents for-profit nursing homes.
Nursing homes in these states have been able to make some use of the time since the spring surge in the Northeast.
Personal protective equipment, or PPE, is generally at hand in a way that it was not this spring, officials said, though some advocates worry current supplies will not last long if the disease really catches hold. Health officials have emphasized the importance of infection control — keeping the virus from spreading within a nursing home, from staffers to residents or among residents — but the problem is that employees with the training and ability to maintain rigorous protocols are in short supply. Visits by family members have been curtailed, reducing the risk of introducing the disease, though not without taking an emotional toll on residents.
All the same, the more far-reaching measures that would be needed to keep the virus from spreading have proved difficult or impossible to pursue. Among these are thorough, regular testing with quick results; tapping infection-control experts to properly train staffers; instituting measures to reduce staff risk of exposure outside the workplace; and an upgrade for sometimes-patchy local regulatory system.
Regular testing for the coronavirus, of staffers and residents, is at the top of the list of measures experts say nursing homes should be taking — with isolation for those getting positive results. In Florida, the state is paying for mandatory testing of staff members every two weeks, through at least mid-September. It has contracted with a California company that promises results within 48 hours. The number of positive results among nursing home staffers in the state has declined from nearly 7,300 on July 23 to just over 5,000 on Wednesday, even as the number of infected residents has held steady.
But Florida is an outlier. Texas, Oklahoma and Arizona, for instance, mandated tests for every resident and staff member, but only one round was conducted. The Centers for Disease Control and Prevention says regular testing — twice a month or even weekly — is needed at a minimum. And results in those states, as in most of the country, are taking a week or more to come back, which makes them fairly useless because the virus can become widespread in the interim.
“Testing continues to be a challenge,” said Steven Buck, president and chief executive of Care Providers Oklahoma, a trade group.
The Texas state health department said it plans to pursue additional tests in nursing homes where at least three people test positive. But research in Massachusetts found that the coronavirus can spread so rapidly among a nursing home population that waiting for even a first positive result before acting could make any measures then taken nearly beside the point.
Since mid-July, the cumulative number of coronavirus cases in Texas nursing homes more than doubled to 18,589, as of Thursday, as did deaths, to 2,503. In other nearby states those numbers are rising steadily but still gradually.
A question, especially for nursing homes that have to make a profit off the relatively low payments they receive from Medicaid, is how any additional testing would be funded. The Cares Act coronavirus-relief measure passed in March provided $4.7 billion in aid to nursing homes. An additional $2.7 billion in federal funds was also made available by the administration.
Officials and trade groups say much of that has gone to purchasing PPE and paying bonuses and overtime to badly stretched staffs. President Trump announced July 22 that the White House is making an additional $5 billion available to nursing homes.
The Centers for Medicare and Medicaid Services (CMS), which regulates nursing homes, said it will use some of that money to send 600 rapid testing devices to nursing homes in hot spots, with 15,000 more going out “over the next few months.” These kits can reportedly return results in 15 minutes. The agency said that it “will begin requiring, rather than recommending, that all nursing homes in states with a 5 percent positivity rate or greater test all nursing home staff each week.” Florida, Texas, California, Arizona and Oklahoma are all among states that currently fall above that line.
State health departments report that they have yet to receive any guidance from CMS about the new testing requirement and what their role would be in enforcing it.
A significant factor affecting the ability of nursing homes to contend with the pandemic is a history of rapid staff turnover, which leaves companies scrambling for workers and hinders efforts at rigorous training. Low pay is a major contributor to the problem.
For years, Texas has had one of the worst staff turnover ratios in the United States, Fredriksen said. Under the Cares Act, nursing homes received $50,000 plus $2,500 per bed. Texas officials mandated a $2-an-hour raise for all nursing home employees.
“They’ve had a pretty decent influx of money over a short time,” Fredriksen said of the state’s nursing homes. This, she said, is their opportunity to try to retain staffers. “But people are sick, people are working long hours, and people are scared.”
Another important and obvious step in preventing infection is to pay employees for sick time if they test positive, health experts say, to remove the incentive to keep working through an illness. But Knapp, of the Florida Health Care Association, said that even in her state, sick-leave policy depends on the particular nursing home, and there are no state mandates.
Under the federal Families First Coronavirus Response Act, signed into law on March 18, most companies with fewer than 500 employees are required to pay for sick leave, but the Labor Department issued a rule exempting health-care workers. That rule was struck down by a federal judge in New York on Tuesday.
Health experts also point out that a significant number of generally low-paid employees work in multiple nursing homes to make ends meet and that this is a dangerously easy means by which the virus can spread. Oklahoma and other states have distributed federal guidance urging that employees be limited to one health-related job, but again, there are no mandates.
In the Northeast, nursing homes with more registered nurses on staff generally had better outcomes than those with fewer RNs, attributed by nursing school experts and health officials to more-sophisticated infection-control efforts. Southern and southwestern states have not made the hiring of additional RNs, typically high-paid in comparison with other staff members, a requirement or priority.
“For the facility, it’s the reality of the money crunch,” Shelley said. “It would be nice to have more of them.”
The closest any Sun Belt state has come to a mandate regarding RNs is in Texas, where 81 percent of nursing homes have been cited for infection-control violations in the past three years. The health department as a response implemented what it calls the Quality Monitoring Program. It provides what Fredriksen called a “strike force” consisting of RNs, pharmacists and other health professionals who help nursing homes ramp up their infection-control measures. “It’s really designed to put professionals in the building,” she said.
Resources under the program “can include infection control assessments by epidemiologists, site assessments, testing, patient assessments, PPE distribution, and disinfecting services,” Kelli Weldon, press officer for the state health department, said in an email.
In Oklahoma, Buck said, nursing homes seeking grants from federal funds were required to present infection-control plans. In Arizona, every licensed skilled nursing facility “has received at least one onsite infection control survey, with ongoing survey activity when new cases are identified,” Holly Poynter, a public information officer for the state Department of Health Services, said in an email.
State health departments are not, in general, huge agencies. They have regulatory power but are not equipped to deal with the widespread course of action that a pandemic requires.
In California, for instance, critics say the state expects too much of local agencies in carrying out its directives.
“While the state has required that facilities come up with plans for comprehensive testing, they have not offered any meaningful assistance in getting any testing done, relying instead on the idea that county departments of public health would shoulder this burden,” Mike Dark of California Advocates for Nursing Home Reform said in an email. “For many rural and poor counties, especially after covid-19 carved a crater in tax revenues, there just aren’t any resources to get this done, so the plan is just a mirage.”
Similarly, he wrote, the poorer counties do not have the means to provide help with obtaining PPE, or even training nursing home staffers in how to use it properly. And the determination to “cohort” and isolate residents who have tested positive varies widely from nursing home to nursing home.
“Some do, and some do not,” he wrote. “But cohorting and isolating is useless if you have the same sick and overworked aides seeing covid-positive and covid-negative residents.”
Optimism, as the virus continues to rage, is carefully couched. “This is not a short-term sprint,” Buck said. “This is looking to be a marathon for the industry. We’re going to have to pull together every ounce of that can-do spirit.”
Pessimism, on the other hand, is straightforward.
“More and more of us are looking around the corner and not hoping this will be over in the next couple of weeks,” said Shelley, in Harris County, Tex. “Hope’s valuable. Right now it doesn’t feel like there’s a lot of it.”
Debra Cenziper contributed to this report.