Trump administration charts a slow path for reopening nursing homes

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By Amy GoldsteinDebbie Cenziper and Maria Sacchetti, The Washington Post, May 18 2020

Ambulance workers move a man from the Life Care Center in Kirkland, Wash., into an ambulance in March. The facility was the epicenter of a covid-19 outbreak in the Seattle region, with 45 deaths. (Ted S. Warren/AP)

The Trump administration on Monday issued guidelines that urge caution in reopening the nation’s nursing homes, recommending that the facilities — battered by the novel coronavirus — relax restrictions more slowly than the communities around them.

The guidelines urge state and local officials to refrain from allowing virtually all visitors into nursing homes or other senior care facilities until several conditions are met. They include making sure a nursing home has no new cases of covid-19, the disease caused by the coronavirus, for four weeks.

In addition, such facilities must ensure that they have enough protective gear and access to coronavirus tests and that nearby hospitals have sufficient space in intensive care units and other wards in the event cases spike again. The guidance also says the amount of virus circulating in the community should be taken into account.

The guidance is an aspect of the White House’s Opening Up America Again plan, and it has phases, like the broader plan. But it sets a significantly higher bar for resuming normal operations in nursing homes filled with vulnerable, elderly residents than the guidelines for businesses, stores and other workplaces — all of which President Trump has been encouraging to turn the lights back on.

“While we are not at a point where nursing homes can safely open up, we want to make sure communities have a plan in place when they are ready to reopen,” said Seema Verma, administrator of the Centers for Medicare and Medicaid Services (CMS), which issued the guidance.

On a Monday evening conference call with reporters, Verma said “extreme caution” should be used by state and local officials, who will have the final say on whether to follow the federal advice.

She said the recommendations were developed in consultation with Brett Giroir, the Health and Human Services assistant secretary overseeing coronavirus testing, and Deborah Birx, the coronavirus response coordinator for the White House’s coronavirus task force. The nursing home industry was consulted, as well.

Although it recommends a careful, gradual approach, the nursing home guidance nevertheless reflects a tendency in the Trump administration for policy decisions sometimes to run ahead of facts on the ground.

CMS, which regulates nursing homes, issued the guidelines on Monday afternoon, hours after the deadline for the nation’s nursing homes to report their number of coronavirus infections and deaths to the federal government — something watchdogs for the elderly had been urging. Nursing facilities also must report on staff shortages, access to protective gear and the availability of ventilators.

Federal officials said they will collect that information weekly and publish it online, starting by the end of May, showing figures for individual nursing homes as well as broad patterns. As a result, the administration’s guidance for slowly relaxing restrictions was written as health officials were just starting to study that data.

The massive data collection marks the U.S. government’s first attempt to assess the virus’s impact since an outbreak in a Seattle nursing home in February killed 45 people, according to the King County, Wash., public health department.

Monday’s recommendations are appearing slightly more than two months after CMS issued its last nursing home guidance, in which health officials said facilities should “restrict visitation of all visitors and non-essential health care personnel.” The only exceptions, it said in the March 13 guidance, are for “certain compassionate care situations,” such as when a patient is dying, and those decisions should be made case by case, with visitors required to wear protective gear, including face masks.

Even before the government provides a statistical roundup, it has been evident that long-term care facilities are among the settings the coronavirus has penetrated most deeply. One in four nursing homes nationwide have reported at least one case of covid-19, according to a Washington Post analysis of publicly available data for more than 15,000 skilled nursing facilities certified by Medicare and Medicaid, the public insurance programs for older Americans and for the poor.

And in the absence of a government tally of coronavirus-related deaths in nursing homes, the Kaiser Family Foundation, a nonpartisan health-care policy organization, has estimated that those facilities and other assisted-living facilities account for 41 percent of covid-19 deaths in the United States, based on publicly available state data. In some states, the proportion is as high as 70 percent or 80 percent of the total deaths, Kaiser has said.

Leading advocates for nursing home residents and their families were swiftly critical of the CMS recommendations, from various vantage points.

Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, criticized the administration’s approach, saying in an email: “As usual throughout the pandemic, the federal government is once again putting responsibility on governors and others to make actual decisions. . . . We need national standards, based on science and expert advice, that everyone follows, not recommendations that can be ignored.”

Michael Wasserman, president of the California Association of Long Term Care Medicine, faulted government officials for not relying more on geriatricians and other experts in long-term care to decide when facilities can safely open. “That’s what we trained for our whole lives,” he said.

And Mike Dark, a lawyer with the nonprofit group California Advocates for Nursing Home Reform, said the guidelines “could mean waiting for months or years before crucial caregiver visits can start again.” In an email, he said: “The virus is already so widespread in facilities, and access to testing so limited, that asking for all residents and staff to test negative first means residents and families will lose hope of seeing one another again. . . . These are issues that CMS has already badly dropped the ball on, and now they’re making families pay the price for it.”

Verma said covid-19 deaths among nursing homes residents have “been heartbreaking,” as was the agency’s March decision to bar visitors.

She said the pace of reopening would vary, nursing home by nursing home, depending on its history with the virus and that of its community. “We want to unite families with their loved ones,” she said, “as soon as it is feasible and safe.”