NACo Brief: Nursing Homes & COVID-19

• Background
• Key Updates
• Data
• Overview of Federal Guidance
• County Best Practice Examples
• Federal Advocacy Messages

Skilled Nursing Facility (SNFs)

These facilities provide senior care, meal preparation, and non-medical assistance, but also have specialized staff such as speech-language pathologists, rehabilitation specialists, audiologists, among others. Skilled nursing care is typically provided for rehabilitation patients that do not require long-term care services. This type of care is also referred to as post-acute care, in that it typically is provided following an emergency hospital stay.

Nursing Home

These facilities also provide care to residents with the presences of certified nurses, meal preparation, and non-medical assistant like bathing; however, they lack the on-site licensed medical practitioners of a skilled nursing facility. Nursing home facilities are also known as long term care (LTC) or extended care facilities (ECF). They provide more permanent care, as oppose to the more transient nature of skilled nursing facilities, however nursing homes and SNFs can be combined.

Key Updates

NACo made several key updates to this brief to reflect the changing landscape of COVID-19 prevention and mitigation efforts in long-term care environments, including:

• New data on COVID-19 vaccinations in long-term care facilities
• New data on staffing trends in long-term care facilities since the start of the pandemic
• An overview of federal guidance on vaccinating staff and residents
• Updated guidance on staff protocols, resident co-horting, screening of residents and healthcare professionals, and implementing visitation restrictions
• An updated overview of reporting and transparency guidance
• An updated overview of provisions in COVID-19 legislative packages & standalone bills
• New county best practices
• And updates to federal advocacy messages.

Kentucky

-35%

New Hampshire

-19%

California

-14%

Connecticut

-14%

South Carolina

-12%

Spotlight Resource: The Federal Long-Term Care (LTC) Ombudsman Program

Authorized by the Older Americans Act and administered by the Administration on Aging (AoA), the federal Long-Term Care (LTC) Ombudsman program operates in every state and the District of Columbia. State Ombudsmen—typically located in State Units on Aging—designate staff and thousands of volunteers statewide as representatives to directly serve residents of nursing homes, board and care homes and assisted living facilities, addressing complaints and advocating for improvements in the long-term care system. LTC Ombudsman duties include visiting residents regularly, addressing and resolving quality of care and safety issues, training staff, families and residents on resident’s rights and abuse prevention, helping prevent inappropriate evictions and more.

Guidance from the AoA details the important role that LTC Ombudsman programs can play in emergency planning and response. These model policies and procedures:

• Clarify appropriate functions and limitations of Ombudsman programs in preparing for and responding to emergencies affecting long-term care facility residents
• Assist Ombudsman programs in developing program policies and procedures related to emergency preparedness, response, and recovery activities
• Assist State Units on Aging and Area Agencies on Aging to incorporate the functions of Ombudsman into their emergency preparedness planning

Infection Prevention & Control Program

• Assign one or more individuals with training in infection control to provide on-site management of the IPC program. This position should be a full-time role for at least one person in facilities with more than 100 residents.
• Provide supplies necessary to adhere to recommended IPC practices, including placing hand sanitizer in every resident room and care and common areas.
• Provide appropriate PPE to HCP and perform and maintain an inventory of PPE in the facility. Develop a schedule for regular disinfection of shared equipment and high-touch surfaces through the facility.

Educate Residents, HCP and Visitors on COVID-19

• Provide culturally and linguistically appropriate information about COVID-19 infection.
• Provide information about ways to manage stress and anxiety.
• Educate and train HCP and others providing services in the facility, including volunteers, on new policies and procedures and IPC measures.
• Institute a plan to communicate with residents, families and HCP regularly.

Reporting COVID-19 Outbreaks

• Notify the health department if:
  • One or more residents or HCP have or are suspected of having COVID-19;
  • A resident has a severe respiratory infection resulting in hospitalization or death; or
  • Three or more residents or HCP present with acute illness compatible with COVID-19 within 72 hours.
• Inform and update HCP and residents and their representatives promptly about COVID-19 infections in the facility.
• Report COVID-19 infections, facility staffing and supply information and point of care testing data to the National Healthcare Safety Network (NHSN) Long-Term Care Facility (LTCF) COVID-19 Module weekly.

Vaccinations

• LTCFs are required to offer the COVID-19 vaccine to residents and staff members and educate them on the vaccine's benefits and possible side effects.
• LTCFs must report on the COVID-19 vaccine status of residents and staff, each dose of the vaccine receive, COVID-19 vaccination adverse events and therapeutics administered to residents for treatment of COVID-19 to the NHSN LTCF COVID-19 Module.
• Residents and their representatives have the right to refuse COVID-19 vaccination, and facilities should follow state law and facility policies with respect to staff refusal of vaccination.

Source Control

• Residents should wear a well-fitting form of source control – including cloth masks, facemasks or respirators throughout the facility, except within their room (unless someone enters the room).
• HCP should always wear a well-fitting form of source control, including in breakrooms.
• Visitors and others in the facility should always wear a well-fitting form of source control.

Visitation

• Indoor visitation could be permitted for all residents, except in the following situations:
  • Indoor visitation for unvaccinated residents should be limited to compassionate care situations if the COVID-19 county positivity rate is greater than 10 percent and less than 70 percent of facility residents are fully vaccinated.
  • Indoor visitation should be limited to compassionate care situations for:
    • vaccinated and unvaccinated residents with COVID-19;
    • vaccinated and unvaccinated residents in quarantine.
• Facilities in outbreak status should follow guidance from state and local health authorities and CMS on when visitation should be paused.
• Visitors should be screened and restricted from visitation, regardless of vaccination status, if they have COVID-19, symptoms of COVID-19 or had close contact with someone with COVID-19 in the past 14 days.
• Regardless of vaccination status, visitors should wear well-fitting source control and physically distance from those they are not visiting.
  • But, if both the resident and visitor are fully vaccinated, they do not need to wear source control or physically distance when alone in the resident's room.

Personal Protective Equipment

• Facilities should have policies and procedures establishing which PPE is required in which situations and the recommended sequence for safely donning and doffing PPE.
• Reusable PPE must be properly cleaned, decontaminated and maintained after and between uses.
• Implement CDC PPE optimization strategies if shortages are anticipated or exist.
• In facilities in areas with moderate to substantial community transmission and COVID-19 is not suspected in a resident, HCP should follow Standard Precautions and use:
  • A NIOSH-approved N95 respirator or a respirator approved under similar standards in other countries or a well-fitting face mask while n the facility and during resident care encounters.
  • N95 respirators (or an equivalent) or higher-level respirators for all aerosol-generating procedures.
  • Eye protection during patient care encounters.
• In facilities with minimal to no community transmission, HCP should continue to follow Standard or Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses.

Communal Activities & Areas

• Vaccinated and unvaccinated residents who have or are suspected of having COVID-19 or in quarantine should not participate in communal activities.
• If all residents participating in a group activity are fully vaccinated, they can choose not to wear source control or physically distance. If unvaccinated residents are present, they should wear source control and physically distance.
• Fully vaccinated residents can participate in communal dining without wearing source control or physically distancing. If unvaccinated residents are present, all residents should use source control when not eating, and unvaccinated residents should physically distance themselves from others.
• Fully vaccinated HCP should continue to wear source control while at work.
• Fully vaccinated HCP can dine and socialize together in breakrooms and conduct in-person meetings without source control or physical distancing. If unvaccinated HCP are present, everyone should wear source control, and unvaccinated HCP should physically distance.

Testing

• Residents and HCP with COVID-19 symptoms, regardless of vaccination status, such be tested immediately.
• Asymptomatic HCP with a higher-risk exposure and residents with close contact with someone with COVID-19, regardless of vaccination status, should have a series of two viral tests, with the first test, performed immediately and the second performed 5-7 days after exposure.
• In facilities with an outbreak of COVID-19, HCP and residents, regardless of vaccination status, should have a viral test every 3-7 days until no new cases are identified for 14 days.
• Fully vaccinated HCP may be exempt from expanded screening testing.
• Unvaccinated HCP should continue expanded screening testing:
  • In counties with a positivity rate of greater than 10 percent in the past week, unvaccinated HCP should be tested twice a week.
  • In counties with a positivity rate between 5-10 percent in the past week, unvaccinated HCP should be tested once a week.
  • In counties with a positive rate of less than 5 percent in the past week, unvaccinated HCP should be tested once a month.
• Complete testing guidance and requirements are available here.

Evaluating & Managing HCP

• Implement non-punitive, flexible sick leave policies that support HCP to stay home when ill.
• Care activities should be bundled to minimize the number of HCP entries into a room.
• Screen HCP for symptoms of COVID-19 when entering the facility.
• Fully vaccinated HCP with higher-risk exposures who are asymptomatic do not need to be restricted from work for 14 days following their exposure.
• HCP with COVID-19 symptoms should be excluded from work and further evaluated.
• Facilities should be prepared for potential staffing shortages and establish plants to mitigate this issue.

Evaluating & Managing Residents

• Actively monitor residents at least daily for COVID-19 symptoms and prioritize those with suspected infection for testing.
• Vaccinated and unvaccinated residents who have had close contact with someone with COVID-19 should be quarantined for 14 days after exposure.
  • Facilities can consider waiving quarantine for fully vaccinated residents to address critical issues (e.g., lack of space, staff, or PPE) when other options are unavailable.

Cohorting of Residents with COVID-19

• Identify space in the facility dedicated to monitoring and caring for residents with COVID-19 that is physically separate from other rooms or units housing residents without COVID-19.
• Identify HCP who will work only in the COVID-19 care unity, including primary nursing assistants and nurses. HCP should avoid working both in the COVID-19 care unit and other units.
  • Ideally, COVID-19 care unit HCP should have a restroom, breakroom and work area separate from HCP working in other areas of the facility.

Resident Intake and Transfer

• Generally, all new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon entry. Exceptions include:
  • Fully vaccinated residents.
  • Residents within three months of a COVID-19 infection.
• LTCFs in areas with minimal to no community transmission may choose to use a risk-based approach for determining which residents require quarantine upon admission.
• Quarantine is not recommended for residents who leave the facility for less than 24 hours and do not have close contact with someone with COVID-19.

New Challenge: Long Term Care Workforce Shortages

While recent jobs numbers show a number of industries recovering from pandemic job loss, nursing home and residential care facilities have continued to see a steady decline. According data from the Bureau of Labor Statistics, nursing home employment fell by 7.4% from March to April 2021, making April the 15th consecutive month of job loss for this sector that is down 338,000 jobs since peak employment numbers in February 2020. According to the American Health Care Association (AHCA) workforce recruitment and retention has been a persistent challenge for long term care providers due to the ongoing shortage of trained caregivers for critical roles, which may be contributing to the slow job recovery in this sector.

Nursing Home Oversight During COVID-19: The Role of State Survey Agencies (SSAs)

CMS works in partnership with State Survey Agencies (SSAs) to oversee nursing homes. SSAs are responsible for state licensure and make annual visits to nursing homes participating in the Medicare and Medicaid program to ensure compliance with CMS’s health and safety requirements as well as state licensure requirements. SSAs also investigate and validate complaints made my individuals. While CMS suspended non-emergency inspections across the country earlier in the COVID-19 pandemic, in January 2021 SSAs were instructed to resume more routine surveys once a state had entered Phase 3 of the Nursing Home Reopening Guidance. Guidance on these inspections is available here.

What to Report

Who to Report To

When or How Frequently to Report

• Suspected and confirmed COVID-19 infections among residents and staff
• Total deaths and COVID-19 deaths among residents and staff
• PPE and hand hygiene supplies in the facility
• Ventilator capacity and supplies in the facility
• Resident beds and census
• Access to COVID-19 testing while the resident is in the facility
• Staffing shortages
• Vaccine status of residents and staff
• Doses of vaccine received
• COVID-19 vaccination adverse events
• COVID-19 treatment/therapeutics administered

CDC's National Healthcare Safety Network (NHSN)

Weekly

The occurrence of either:

• A single confirmed infection of COVID-19; OR
• Three or more residents or staff with new-onset of respiratory symptoms in a 72-hour period.

Residents, their representatives, and families of those residing in the facility

5 p.m. the next calendar day

Nursing Home Provisions in COVID-19 Packages

Bill Number/Title

Summary

Date Passed

Families First Coronavirus Response Act (PL 116-127)

• For new paid sick and family medical leave provisions, the legislation clarified the definition of essential health care workers to include employees working at nursing home facilities and exempted essential employees from new paid sick and family medical leave requirements and Unemployment Insurance (UI) provisions. NACo's complete analysis of the new leave and UI requirements can be found at this link.

Signed into law March 18, 2020

CARES Act (PL 116-136)

• Within the $100 billion provider relief fund authorized under the CARES Act, the legislation directed $4.9 billion to long-term care facilities for pandemic response activities. A state-by-state breakdown of the funding allocation can be viewed here.
• The bill included a total of $200 million to respond to coronavirus both domestically and internationally, $100 million of which was directed to necessary expenses of the survey and certification program, prioritizing nursing home facilities in localities with community transmission of coronavirus.
• Provided $955 million to Administration for Community Living (ACL) programs, which included $20 million for the Long-Term Care Ombudsman Program to respond to the coronavirus emergency. Ombudsman programs will expand their virtual presence to residents and their families and continue to promote residents' health, safety, and rights in the context of COVID-19. The funds must be expended on allowable Older Americans Act activities defined by the Older Americans Act and state and local policy.
• The legislation also clarified that State Long-Term Care Ombudsman programs must maintain direct (virtual) access to residents of long-term care facilities during any portion of the public health emergency relating to coronavirus.

Signed into law March 27, 2020

Paycheck Protection Program and Health Care Enhancement Act (PL 116-139)

• The legislation added an additional $75 billion to the provider relief fund authorized under the CARES Act, bringing available funds to a total of $175 billion.

Signed into law April 24, 2020

Consolidated Appropriations Act of 2021 (PL 116-260)

• The legislation added an additional $3 billion to the provider relief fund authorized under the CARES Act, bringing available funds to a total of $178 billion.
• The legislation also included provisions that amended provider relief fund reporting guidelines to clarify that lost revenue calculations can be done by any "reasonable" method, including calculating the difference between budgeted and actual revenue on a monthly, quarterly or annual basis.
• The legislation also allows provider relief fund money to be used for staffing expenses and allows health systems to allocate distributions to subsidiary organizations within their system.

Signed into law December 27, 2020

American Rescue Plan Act (P.L. 117-2)

• The legislation provided $500 million to the US Department of Health and Human Services (HHS) to allocate money to states and territories to establish strike teams to respond to COVID-19 outbreaks in skilled nursing facilities.
• The legislation enhanced state Federal Medical Assistance Percentages (FMAP), including a temporary FMAP increase of 7.35 percentage points for states to improve Medicaid home and community-based services for one year.

Signed into law March 11, 2021

Standalone Nursing Home and Long-Term Care Facility COVID-19 Bills

Bill Number/Title

Sponsor

Summary

Status

Quality Care for Nursing Home Residents and Workers During COVID-19 Act (S. 317)

Sen. Cory Booker (D-N.J.), Sen. Richard Blumenthal (D-Conn.)

• Amends the Social Security Act to improve the quality of care for residents and workers in skilled nursing facilities and nursing facilities during the COVID-19 public health emergency. The legislation would establish new quality of care, worker safety and transparency requirements for SNFs and nursing facilities during the pandemic and authorize $500 million for state nursing home strike teams.

Introduced on February 12, 2021, and referred to the Senate Finance Committee

Quality Care for Nursing Home Residents and Workers During COVID-19 and Beyond Act (HR 598)

Reps. Jan Schakowsky (D-Ill.), Mark Takano (D-Calif.)

• Amends the Social Security Act to improve the quality of care for residents and workers in skilled nursing facilities and nursing facilities during the COVID-19 public health emergency. The legislation would establish new quality of care, worker safety and transparency requirements for SNFs and nursing facilities during the pandemic and authorize $500 million for state nursing home strike teams.
• Amends the Social Security Act to improve the quality of care for residents and workers in SNFs and nursing facilities beyond the COVID-19 pandemic. The legislation would change staffing requirements, establish whistleblower protection and implement protocols for obtaining consent before prescribing psychotropic drugs, among other items.

Introduced on January 28, 2021, and referred to the House Ways Means and Energy & Commerce Committees

COVID-19 Nursing Home Protection Act of 2021 (S. 333)

Sens. Bob Casey (D-Pa.), Raphael Warnock (D-Ga.), Sheldon Whitehouse (D-R.I.), Cory Booker (D-N.J.), Maria Cantwell (D-Wash.), Bob Menendez (D-N.J.), Jeanne Shaheen (D-N.H.), Tina Smith (D-Minn.), Amy Klobuchar (D-Minn.), Tammy Duckworth (D-Ill.), Chris Van Hollen (D-Md.), Sherrod Brown (D-Ohio), Catherine Cortez Masto (D-Nev.), Jack Reed (D-R.I), Mazie Hirono (D-Hawaii), Maggie Hassan (D-N.H.)

• Amends the Social Security Act to provide funding for state strike teams, technical assistance and infection control for residents and worker safety in skilled nursing facilities (SNFs) and nursing facilities during the COVID-19 pandemic. The legislation would also require long-term care facilities to report certain demographic information relating to COVID-19 cases and deaths.

Introduced on February 22, 2021, and referred to the Senate Finance Committee

PROTECT Long Term Care Facilities Act (HR 844)

Reps. Mikie Sherrill (D-N.J.), Bill Pascrell (D-N.J.), Donald Payne (D-N.J.), Albio Sires (D-N.J), Judy Chu (D-Calif.), Jimmy Panetta (D-Calif.), Daniel Kildee (D-Mich.)

• Amends the Social Security Act to increase enforcement for skilled nursing facilities (SNFs) and nursing facilities during the COVID-19 emergency period and other infectious disease outbreak periods. The legislation would appropriate $100 million in FY 2021 for State Survey Agencies to conduct increased oversight and enforcement of SNFs and nursing facilities.

Introduced on February 4, 2021, and referred to the House Energy & Commerce and Ways & Means committees

Fairfax County, Va.

To prevent large-scale outbreaks in its long-term care facilities, the county has a response plan in place if one positive case in a facility is detected. The county dispatches a rapid response team to provide training on appropriate personal protective use and general infection prevention practices. Additionally, the county assigns a public health nurse to lead an investigation and provide recommendations when necessary.

Los Angeles County, Calif.

The county uses a four-pronged approach to increase vaccinations in its facilities: Policy & Procedure, People, Culture, and Materials. The county recommends holding regular services to provide information on the vaccines and answer any questions. Additionally, the county recommends empowering a diverse group of vaccine champions to share their vaccine experiences and encourages the community to show compassion to people still considering whether to get vaccinated.

Multnomah County, Ore.

The county advises its long-term care facilities to make broad preparations for when they encounter a positive test. The county recommends that the facilities develop a Continuity of Operations Plan to respond to an outbreak. Additionally, they recommend determining which staff members would care for patients and training personnel to perform essential functions. If a facility encounters a positive test, they require them to test all residents, facility staff and associated staff within three days.

Franklin County, Ohio

Franklin County provides weekly updates on positive case counts among residents and staff in all long-term care facilities in the county. The data, which are easily accessible on the county's website, include cumulative totals as well.

Oakland County, Mich.

The county produced a two-page document with relevant guidelines, action steps, and links that overview how its long-term care facilities had been responding to the pandemic. The document includes procedures for handling visitors, managing outbreaks, and educating staff about COVID-19.

Federal Advocacy Messages

Support policy solutions that help build a strong long-term care workforce. The nursing home and long-term care sector have had persistent challenges with workforce recruitment and retention, an issue only exacerbated by the COVID-19 pandemic, which disproportionately impacted these facilities. According to the Bureau of Labor Statistics data, nursing home employment fell by 7.4 percent from March to April 2021, making April the 15^th consecutive month of job loss for this sector, which is down 338,000 jobs since peak employment numbers in February 2020.

County recovery depends on partnerships at the federal level that will establish a strong health care workforce in long-term care in nursing environments to provide the highest level of care to our most vulnerable residents.

Support legislation that enhances federal aid for skilled nursing and long-term care facility COVID-19 response efforts. Given the tremendous impact that COVID-19 has had on congregate living facilities, counties need congressional support for legislation that enhances federal aid for skilled nursing and long-term care facilities in subsequent COVID-19 packages. Without the tools to effectively manage the spread of the disease in these facilities – including adequate personal protective equipment (PPE), funding for testing, medical supplies and staffing support – counties cannot effectively protect their residents and assist in helping our nation recover from this pandemic.