Nursing homes, Covid-19 hot spots now, resisted emergency planning rules

covidnhnoplan-276x300With hurricanes, wildfires and other calamities, authorities pound home to the public the importance of preparedness. So why should preparing for an infection outbreak be any different? Yet more disclosures have raised disturbing questions about the dearth of crucial emergency planning by nursing homes and other long-term care facilities, their owners and operators, and federal and state regulators.

Taxpayers likely will foot hefty bills — a new estimate says it may be $15 billion  —in the days ahead for facilities’ active resistance to oversight and forward thinking. These lapses played a part in the terrible toll in failing to safeguard the old, sick, and injured, and first responders and health care workers, too, reported ProPublica, a Pulitzer Prize-winning investigative site.

It cites data from AARP about the nationwide deaths in long-term care centers inflicted by the novel coronavirus:

“More than 16,000 nursing home residents and staff have died from Covid-19, representing roughly a quarter of the nation’s known coronavirus deaths. While dire, this figure is an undercount, experts warn, because not all states are publicly reporting data yet. In some states, more than half of coronavirus deaths have come in nursing homes.”

ProPublica says its reporting in New Mexico and North Carolina explains how long-term care facilities so quickly were overwhelmed by the virus — and not just because they are home to some of the nation’s most vulnerable. This is worth quoting at length:

“The lack of pandemic plans helps explain why nursing homes have been caught unprepared for the new coronavirus, patient advocates and industry observers said … Ongoing questions about the regulations may also have played a role … 2016 [federal] rules mandated planning for all kinds of hazards, citing Ebola as an example. In 2019, the Trump Administration clarified that nursing homes needed to include a specific plan for outbreaks of unfamiliar and contagious diseases — such as the coronavirus. The plans must address how facilities will respond in an emergency — specifying how nursing homes will decide to shelter in place or evacuate and how they will provide residents with food, water, medicine and power. Nursing homes have to train their staff on these plans and practice them at least twice a year, if possible, by participating in a drill with local agencies.

“Some nursing homes were slow to comply, according to an analysis of inspection data, watchdog reports and interviews with ombudsmen and advocates. Inspectors have found more than 24,000 deficiencies with nursing homes’ emergency plans between November 2017, when the so-called ‘all hazards rule’ took effect, and March 2020, according to public data …The violations occurred in 6,599 facilities, equal to about 43% of the country’s nursing homes.

“Because of how the Centers for Medicare and Medicaid Services tracks the data, it’s not possible to say exactly how many of the emergency planning violations related specifically to a failure to plan for an infectious disease outbreak. Failures to meet routine infection control standards were excluded from the analysis. But nursing home advocates say that more detailed plans … for expected staff and equipment shortages would have likely resulted in fewer deaths and illnesses at nursing homes stricken by the coronavirus. The current rule requires nursing homes to make contingency staffing preparations, but it doesn’t require stockpiles of personal protective equipment, or PPE. ‘It’s just a river of grief, and it could have been prevented,’ said Pat McGinnis, executive director of California Advocates for Nursing Home Reform.”

The ProPublica digging shows why inadequate planning not only posed risks to long-term care facilities, their residents, and staff, but also to others outside — notably first responders and health care workers. If federal rules had been followed, the facilities would have conducted periodic exercises, giving police, fire fighters, emergency medical techs, and health care workers at clinics and hospitals a better sense of how they might need to respond in dire circumstances.

Instead, as an early incident in a Kirkland, Wash., nursing home showed, overwhelmed long-term care facilities sometimes verged on systemic collapses, calling on significant emergency resources to rescue frail, sick, and injured patients with coronavirus infections and in need of extreme treatment. That meant that first responders got overwhelmed and sick, as did health care workers in hospitals flooded with patients from the facilities. And, as NPR reported:

 “More than 60,000 health care workers have been infected, and close to 300 have died from Covid-19, according to new data from the Centers for Disease Control and Prevention. The numbers mark a staggering increase from six weeks ago when the CDC first released data on coronavirus infections and deaths among nurses, doctors, pharmacists, EMTs, technicians and other medical employees. On April 15, the agency reported 27 deaths and more than 9,000 cases of infection in health care workers. The latest tally doesn’t provide a full picture of illness in this essential workforce, because only 21% of the case reports sent to the CDC included information that could help identify the patient as a health care worker. Among known health care workers, there was also missing information about how many of those people actually died.”

ProPublica says that operators of nursing homes, assisted care, and other long-term facilities for the aged, sick, and injured complained to the Trump Administration that emergency planning would be too costly and demanding, especially given that their low-paid staffs experience frequent churn and would require more intensive education than, say, might be required of many highly trained health workers.

Previous investigations by news organizations like the nonpartisan, independent Kaiser Health News (KHN) service have reported on the Trump Administration’s laxity in regulating nursing homes. They let them self-report — and effectively self-police themselves — on, for example, the crucial quality and safety measure of staffing. That changed only after KHN reported on this oversight blunder, including with residents’ loved ones asking why, on evening and weekend visits, so many facilities were all but bereft of nurses or medically trained staff, as regulations require. Oh, the industry replied — when visitations run heavier, less staff are needed because loved ones provide (free) supervision.

Lest cynics belittle emergency plans and preparations as burdensome, wasteful bureaucracy, ProPublica reminds that the nation got an ugly eyeful of what occurs when such work doesn’t get put in — how did regulators, politicians, and the public forget the trauma, harms, and deaths that occurred with long-term care residents during repeated hurricanes and wildfires?

Hospitals, it should be noted, take emergency preparedness with gravity, a West Coast colleague reported. At a big medical center in the West, in an area known for frequent natural and man-made crises, institutional and operational leaders at least once a quarter were forced into emergency exercise more akin to war games. They featured complex and evolving scenarios requiring responses over as long as two days by the dozens of participants. Natural disasters. Terrorism. Biohazards. Radioactive releases. Utility mishaps and failure. Top executives led, took part in, or observed staff, challenging how situations unfolded. Community leaders, law enforcement, fire fighters, federal officials and the military sometimes were included. Some exercises grew to such an extent that patients, neighbors, passers-by, and media organizations had to be clued in to ensure they did not mistake the drills for reality.

In contrast, America’s nursing homes and other long-term facilities have been a festering mess waiting to worsen, as experts have reported in the respected New England Journal of Medicine (NEJM). It, again, is worth quoting at some length:

“[N]ursing homes were sitting ducks for Covid-19, housing people who are particularly vulnerable to poor outcomes of the virus, often in shared living quarters and communal spaces, making social distancing or isolation difficult, if not impossible. But this crisis in nursing homes is not a new problem. Long-term care in the United States has been marginalized for decades, leaving aging adults who can no longer care for themselves at home reliant on poorly funded and insufficiently monitored institutions. Although major regulatory policies, including the Federal Nursing Home Reform Act of 1987, have attempted to address deficiencies in the quality of care, Covid-19 has highlighted the fact that better monitoring is not enough. The coronavirus has exposed and amplified a long-standing and larger problem: our failure to value and invest in a safe and effective long-term care system.

“Indeed, long-term care has been sidelined in our federal social welfare policies since the 1960s, when Medicare and Medicaid created narrow and incomplete social insurance programs for such care. These programs adopted a medicalized model of care, prioritizing the use of licensed providers and institutions. This model made nursing homes the default provider of long-term care and made the care provided by families and others outside these licensed facilities invisible, leaving it unsupported. Furthermore, Medicare and Medicaid were never intended to pay for the lion’s share of long-term care. Medicare funds long-term care only temporarily and tangentially by covering nursing home–based rehabilitation after a hospital discharge. Medicaid finances more than half of all long-term care for people who need help with daily activities, such as bathing, dressing, or eating, but it’s available only to people who have spent down their own assets, and it has coverage gaps. And financing of nursing home care by both Medicare and Medicaid has been declining.”

The Pennsylvania health care experts underscore a painful point:

“In the short term, nursing homes will have to be saved, because despite their vulnerabilities, they are a necessary part of any solution. Some advocates estimate that it will take up to $15 billion in federal funds for nursing homes to survive the Covid pandemic. Recent congressional relief packages have started to address the anticipated shortfall, though experts say they will not be enough. Beyond the pandemic, we will have to transform the way we pay for and provide long-term care.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by abuse and neglect in nursing homes and other long-term care facilities. As the Penn experts observe, the nation has put itself in a quandary with dealing with the elderly (a huge and rapidly growing population), chronically ill, and injured and their need for sustained care. It is crushing for middle-class loved ones, and even those who make more, to afford the $100,000-a-year tab for a single-room in a nursing home. But those in need also have few options, as the complicated, harried lives and livelihoods of so many of us — including with rising singlehood — simply can’t handle further demands.

An expert with the California Advocates for Nursing Home Reform, discussed in a recent blog-published interview the awful consequence of Americans’ blindness toward the growing problems in nursing homes, starting with the key component of who cares for their residents and their high needs. As the interviewer and the expert agree in this slice of a Q-and-A:

“Some 600,000 nursing assistants are the backbone of long-term care facilities. The typical assistant earns just over $13 per hour. The public frequently hears about the difficulty hiring staffing. How is this an issue in a pandemic?  Because of the physical nature of nursing assistants’ work — repeated turning, lifting, and transporting of patients — their likelihood of injury is three times greater than that for the general population. Not surprisingly, staffing shortages and rapid turnover are endemic. It’s also generally considered a low-quality, low-paid position without a lot of opportunities to be promoted. Nursing homes use a lot of immigrant labor, and a lot of times English is a second language. They’re good people, but it’s a vulnerable, exploitable labor pool. They’re also asked to do a whole lot with not enough time, so there’s no other way to get their job done without cutting corners. Another problem is that they don’t get sick pay and they can’t sacrifice the pay, so they show up for work and try to hide the fact that they’re sick. Life Care Center in Kirkland, Wash., had the first huge outbreak, and there were reports that many of the staff working in multiple facilities were coming in when they were sick.”

We’ve got a lot of work to do to deal with the continuing, unacceptable infections and deaths in our nursing homes and long-term care centers — a problem that, again, may be willfully understated. We need to hold owners, operators, regulators, politicians, and others to account for demonstrable neglect, abuse, and downright criminal conduct that has left so many with the least with the most awful Covid-19 illness and deaths. By the way, if anyone flinched at the thought of spending $15 billion to better the lives of the 1.5 million-plus residents of nursing homes and long-term care facilities, a quick reminder: The leader of the free world wants to fork over $11 billion for a wall with dubious prospects for better safeguarding our borders.

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