By Vanna R. Milligan
Older people are at a higher risk for COVID-19. So are people with chronic medical conditions, such as heart disease, diabetes, kidney disease, and respiratory illness. Both groups are heavily represented among the nation’s 1.3 million nursing home residents. That concentration is a key reason why approximately 35% of deaths from COVID-19 have occurred in nursing homes and other long-term care facilities, according to tracking by the Kaiser Family Foundation. Other characteristics of long-term care facilities that contributed to the high infection rate included: lack of personal protective equipment (PPE); frequent physical contact between residents and staff; employees who work in multiple facilities; residents sharing rooms; and the transfer of residents from hospitals and other settings.
In response to the devastating impact COVID-19 was having on long-term care residents, facilities were placed on lockdown in March 2020. This included a suspension of state and federal surveys and inspections, almost no visitors, and suspension of in-house group activities. More than a year later, this article will look at the cautious re-opening that is beginning in long-term care facilities based on federal guidelines. Additionally, this article will discuss current requirements and potential long-term effects of the COVID-19 pandemic for long-term care facilities.
A Cautious Re-Opening Amid the Pandemic:
In March 2021, the Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), issued updated guidance for nursing homes to safely expand visitation options during the COVID-19 pandemic.
These guidelines came as more than three million doses of vaccines were administered within nursing homes. That number has since increased to more than four million doses. According to the updated guidance, facilities should allow responsible indoor visitation at all times and for all residents, regardless of vaccination status of the resident, or visitor, unless certain scenarios arise that would limit visitation for:
- Unvaccinated residents, if the COVID-19 county positivity rate is greater than 10 percent and less than 70 percent of residents in the facility are fully vaccinated;
- Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated, until they have met the criteria to discontinue transmission-based precautions; or
- Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine.
The updated guidance also emphasizes that “compassionate care” visits should be allowed at all times, regardless of a resident’s vaccination status, the county’s COVID-19 positivity rate, or an outbreak. Compassionate care visits include visits for a resident whose health has sharply declined or is experiencing a significant change in circumstances.
CMS continues to recommend facilities, residents, and families adhere to the core principles of COVID-19 infection control, including maintaining physical distancing and conducting visits outdoors whenever possible. This continues to be the safest way to prevent the spread of COVID-19, particularly if either party has not been fully vaccinated.
“CMS recognizes the psychological, emotional and physical toll that prolonged isolation and separation from family have taken on nursing home residents, and their families,” said Dr. Lee Fleisher, MD, CMS Chief Medical Officer and Director of CMS’ Center for Clinical Standards and Quality. “That is why, now that millions of vaccines have been administered to nursing home residents and staff, and the number of COVID cases in nursing homes has dropped significantly, CMS is updating its visitation guidance to bring more families together safely. This is an important step that we are taking, as we continue to emphasize the importance of maintaining infection prevention practices, given the continued risk of transmission of COVID-19.”
High vaccination rates among nursing home residents, and the diligence of committed nursing home staff to adhere to infection control protocols, which are enforced by CMS, have helped significantly reduce COVID-19 positivity rates and the risk of transmission in nursing homes. Although outbreaks increase the risk of COVID-19 transmission, as long as there is evidence that the outbreak is contained to a single unit or separate area of the facility, visitation can still occur.
- For additional details on the updated nursing home visitation guidance released, visit here: https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf
- A Fact Sheet can be found here: https://www.cms.gov/newsroom/fact-sheets/cms-updates-nursing-home-guidance-revised-visitation-recommendations
Current Requirements and Potential Long-Term Effects of COVID-19 on Long-Term Care Facilities:
Several federal requirements for long-term care facilities have already emerged in response to the pandemic. First, a reporting requirement for nursing homes became effective on May 8, 2020. CMS-certified long-term care facilities (skilled nursing facilities and/or nursing facilities) are required to report the following: (1) suspected and confirmed COVID-19 infections among residents and staff, including residents previously treated for COVID-19; (2) total deaths and COVID-19 deaths among residents and staff; (3) personal protective equipment and hand hygiene supplies in the facility; (4) ventilator capacity and supplies in the facility; (5) resident beds and census; (6) access to COVID-19 testing while the resident is in the facility; (7) staffing shortages; and (8) other information specified by the secretary. Facilities are required to submit data at least once a every seven days via the CDC National Healthcare Safety Network’s COVID-1 9 Module.
- Additional information on the CDC National Healthcare Safety Network’s COVID-19 Module can be found here: https://www.cdc.gov/nhsn/ltc/covid19/index.html
Facilities must also provide prompt notification and cumulative updates to their residents, resident-representatives, and residents’ families by the end of the next day – calendar day, not just business day: (1) whenever there is a confirmed COVID-19 case among residents or staff; or (2) whenever there are three or more residents or staff who experience a new onset of respiratory symptoms occurring within 72 hours of each other. The information report must not include personally identifiable information. Facilities must also provide updates on mitigation actions being implemented to prevent or reduce the risk of transmission, including the extent to which normal operations or the facility will be altered.
Guidance issued by the CMS Quality, Safety & Oversight Group suggests there are a variety of ways that facilities can meet the new resident-reporting requirement, including listservs, website postings, paper notification and/or recorded telephone messages. CMS does not expect facilities to make individual telephone calls to each resident, resident’s family, or responsible party.
To ensure compliance with new reporting requirements, CMS has updated its various protocols for COVID-19 by creating two new deficiency tags. Under new tag F884, facilities that have not complied with the new reporting requirement will be subject to civil monetary penalties (CMP). The amount of the CMP begins at $1,000 for the first occurrence of non-compliance and increases by $500 for each subsequent time the facility fails to report COVID-19 related data. The compliance reporting requirements will be assessed weekly and the regulation will continue to be in effect for up to one ear beyond the end of the public health emergency.
- Additional information on the CMS notification requirements for nursing homes can be found here: https://www.cms.gov/files/document/qso-20-29-nh.pdf
Undoubtedly, the pandemic has taken a major toll on the long-term care industry. A year into living with COVID-19, the long-term regulatory and economic impacts of the virus are unknown. Based on reports to date, below is a discussion of potential long-term effects:
- Costs. Facilities may have to redesign interior space to maximize infection control. This may mean facilities will lose beds if they must close shared rooms. Additionally, the pandemic has led to an ever-increasing demand for and strain on healthcare workers. This could mean that facilities see an increase in labor costs.
- Balancing Safety and Risks of Social Isolation. Facilities have an obligation to keep their residents as safe as possible, and after the pandemic they will be under enormous regulatory and consumer pressure to maximize infection control. So far, facilities have been doing that by keeping residents in their rooms – no visitors, few activities, and no community dining. However, social isolation is itself dangerous. Facility residents need the physical, emotional, and spiritual support received from visits and social interaction. The challenge for facilities will be finding a balance between safety and a comfortable, engaging, and social community.
- Marketing. Even before COVID-19, older adults strongly preferred to age at home. Now, whenever possible, aging adults will be more motivated to stay at home. Likewise, their children may be increasingly reluctant to move loved ones into a facility. Unless facilities can demonstrate appropriate responses to the issues posed by the pandemic, facilities will have a hard time marketing around new-found opinions and hesitancy related to admissions to facilities.
- Legal Liability. Unless Congress grants them some waiver of legal liability, long-term care facilities are facing a massive wave of lawsuits from families of residents who became sick or died. Even with a waiver, it is uncertain how this pandemic will affect insurance companies and their willingness to issue policies that cover future pandemics.
- Telemedicine. The pandemic is already shifting the day-to-day logistics of seeing a doctor. As soon as models began to predict that hospital systems could be overwhelmed by a surge of COVID-19 patients, CMS changed its policies surrounding telemedicine, allowing health systems to bill for remote appointments that previously would not have been eligible for reimbursement. That meant more people were able to receive care remotely who would have otherwise created crowded hospitals and taken up valuable bed space. This forced familiarity with telemedicine, in conjunction with home health services, could lead to a preference and option for aging populations to remain at home rather than entering long-term care facilities.
Additional Resources for Long-Term Care Facilities:
- Kentucky Long-Term Care COVID-19 Resources can be found here:
- CMS COVID-19 Nursing Home Data can be found here: