The Trump administration convened a panel of nursing home operators and administrators, academics and state health officials to recommend ways to step up protections for nursing home residents amid the covid-19 pandemic, and this week it received the advice: More money for testing, for personal protective equipment, for registered nurses, for infection control training and staff salary increases.
The report, commissioned by the Centers for Medicare and Medicaid Services, noted that nursing homes have borne the brunt of the pandemic — with more than 50,000 residents and staff dead so far — and argued that public resources to deal with the disease have been lacking.
Nonetheless, Seema Verma, head of CMS, called the report “a resounding vindication of our overall approach to date.”
However one member of the panel differed with Verma’s assessment in a Tweet.
Several have asked about press release suggesting Nursing Home Commission report "validates" federal response. Purpose of report was to provide CMS with roadmap out of crisis, not evaluate federal response (which has been lacking imo). Lots of work to do.https://t.co/tIr1cwuAbv— David Grabowski (@DavidCGrabowski) September 17, 2020
Another member, Jeannee Parker Martin, head of LeadingAge California, the trade group for non-profit nursing homes, also pushed back.
“COVID-19 has exposed many flaws in our nation’s approach to caring for older adults, including longstanding chronic underfunding, a lack of access to staff and training, and more recently a poorly coordinated response and distribution of PPE, testing and resources needed to protect vulnerable older adults," she said. "While the administration has responded with some effort, there is much more to be done to improve the quality and care for the 1.2 million residents in more than 15,000 nursing homes across the country.”
But patient advocates were quick to criticize the 186-page report, made public Wednesday, for its failure to mention accountability on the part of nursing homes. The panel, which met a half dozen times in closed sessions over the summer, had 25 members, with nursing home representatives and their allies heavily represented.
One member, Eric Carlson, of an organization called Justice in Aging, declined to endorse the report.
“There needs to be some responsibility,” he said. “You need facilities that are accountable and to make good use of the money they are getting.”
He applauded the report for urging the careful resumption of family visits, which have been sharply restricted or prohibited in many states, and agreed that the federal government should take on the burden of testing and providing PPE during the pandemic. The report properly recognizes the tough job faced by nursing assistants, but much of the rest, he said, “is just aspirational if anything.”
He scoffed as he quoted from the report: “ ‘Mobilize resources.’ Yeah whatever. ‘Urge nurses.’ You can urge nurses all you want. It’s the facilities’ responsibility to provide quality of care.”
Mark Parkinson, the head of the American Health Care Association, the trade group representing for-profit nursing homes, welcomed the report. His organization has been energetically lobbying for more federal emergency assistance for nursing homes, on top of the $5 billion already dispensed.
“We are pleased to see the commission acknowledge what we have been saying from the beginning — there must be shared responsibility with public health officials prioritizing our residents in long term care and helping facilities acquire necessary resources to combat this global pandemic,” he said in a statement. “As we prepare for a potential rise in cases this fall, we must arm nursing homes and other long term care facilities with a steady stream of resources to ensure they have adequate tests, personal protective equipment and staff support.”
The report did not a put a price tag on its recommendations, and suggested that some of the expense should be shouldered by the states. It did advocate a permanent 12 percent increase in annual per-bed Medicaid payments — or about $10,000 a bed — to be used to increase staff salaries and buy equipment. There are about 1.7 million federally certified nursing home beds nationwide.
The recommendations in the report to beef up infection control training and procedures are sensible, said Charlene Harrington, a professor emerita at the University of California at San Francisco who has studied nursing home finances. But it’s clear, she added, that nursing home operators favor a better short-term design for warding off the disease as long as their own added expenses are minimal.
The report “does nothing to address the crucial issue of weak federal enforcement of standards intended to protect residents of nursing homes, and the blame that nursing home operators must share in creating the conditions that let COVID spread so catastrophically in these facilities,” Mike Dark, an attorney for California Advocates for Nursing Home Reform, a nonprofit watchdog group, wrote in an email.
One factor that public health experts have pointed to as the disease spread is the common practice among nursing home staff of holding down more than one job, in more than one facility. Typically low-paid workers do that to make ends meet, but it’s an effective way to introduce the virus to new settings. Vincent Mor, a professor at Brown University who studies nursing homes, and who was not on the panel, said there was disagreement over a series of recommendations labeled “workforce ecosystem.”
In the end, the report did not urge a halt to the practice of working in multiple homes — even as some states have tried to impose one — but simply recommended that steps be taken to make it safer.
Toby Edelman, of the Center for Medicare Advocacy, applied to be a member of the panel, officially called the Coronavirus Commission for Safety and Quality in Nursing Homes, but was turned down. She said she understands it was convened to deal with the immediate crisis of the pandemic. But she was disappointed that “there’s no discussion of what really needs to be done going forward.”
“We can’t have the nursing home system go back to the way it was,” she said.
For decades, she said, nursing homes have been understaffed, and staff has been underpaid. A 2000 report found that 90 percent of nursing homes needed more staff, and she said that nothing much has changed. This leads to staff people cutting corners, and inevitably some will spread infection, she said.
Low pay is a big factor in staff shortages. “What we really need is for people to get a living wage,” she said.
She echoed Dark in saying the report should have dealt with the lax enforcement system, which is supposed to prevent health-related deficiencies in nursing homes, and the failure to impose strict financial accountability on nursing homes that are typically managed by a slew of limited liability companies. Moreover, she said, “The states do not do a good job in controlling licenses. Anybody can buy anything they want.”
Sen. Bob Casey (D-Pa.) took exception to the way CMS described the report as a validation of the Trump administration’s handling of the disease in nursing homes.
“It’s clear that the Trump administration has failed America’s nursing homes, their residents and their workers,” he said. “Irrespective of what this report says or not, the Centers for Medicare and Medicaid Services congratulating themselves on a job well done is a slap in the face to every American who has lost a loved one in a nursing home during the pandemic."
The commission was organized by a consulting firm called MITRE, which then wrote the report.
“Members wrestled with challenging, sometimes competing, issues such as weighing infection control practices against psychosocial needs of residents,” Jay Schnitzer, chief medical and technology officer at MITRE, and moderator of the commission, said in a statement. “These complex issues do not have easy solutions, which made the diverse experience and insights of members integral to developing the recommendations and actions endorsed in the final report.”
The report was to be presented to Vice President Mike Pence Thursday.
Alexa Mikhail contributed reporting.