Nursing home residents are especially vulnerable. Feds are cutting back on inspections

Carol Marbin Miller, Daniel Chang
·8 min read

Note: The Miami Herald and McClatchy news sites have lifted the paywall on this developing story, providing critical information to readers. To support vital reporting such as this, please consider a digital subscription.

At a time when older Americans are especially vulnerable to the coronavirus, federal health administrators have halted most inspections of nursing homes, hospitals and other healthcare facilities.

The stated reason: This will enable them to zero in on institutions where residents are at greatest risk of contracting the virus — as opposed to focusing on more typical problems such as pressure sores and unsanitary conditions.

The Centers for Medicare and Medicaid Services, or CMS, a federal agency that regulates nursing homes and healthcare facilities, issued the new rules on March 4. The rules allow regulators to continue inspecting homes where residents are in “immediate jeopardy” of death, abuse or neglect. But the emphasis, regulators say, will be on containing the spread of the coronavirus.

Some advocates fear the new rules, which will remain in effect indefinitely, are merely an effort to exploit the public health crisis to further weaken government oversight — a longtime goal of the industry.

Speaking at a teleconference hosted by the American Association of Retired Persons or AARP on Tuesday, CMS Director Seema Verma said, “We want to make sure hospitals and nursing homes and all of our healthcare facilities are doing everything they can to prevent spread of the disease inside these facilities.”

Verma said the guidelines are similar to advice that federal health regulators issue each year during flu season to prevent spread of disease, though it is not clear if CMS has ever suspended non-emergency inspections in response to an epidemic. She added that Medicare and Medicaid, the government-sponsored health insurance plans for older and low-income Americans, will cover tests for the coronavirus with no out-of-pocket costs for beneficiaries.

In its new guidance, CMS also released protocols for investigating facilities with suspected cases of COVID-19 — the illness caused by the coronavirus — which poses the greatest threat to frail elders.

“CMS is suspending non-emergency inspections across the country, allowing inspectors to focus on the most serious health and safety threats like infectious diseases and abuse,” the memorandum by CMS’ Center for Clinical Standards and Quality said. “This shift in approach will also allow inspectors to focus on addressing the spread of coronavirus disease 2019.”

In a revised notice issued Monday, CMS also advised nursing home administrators to screen and restrict visitors showing symptoms of a respiratory infection, such as a fever, cough, shortness of breath or sore throat. Nursing home administrators are advised to restrict visits by anyone who has had contact with someone with a confirmed diagnosis of COVID-19 or who has visited a country with sustained transmission of the disease within the past 14 days.

Health regulators so far have identified only one nursing home in the United States with widespread infection of the virus. Thirteen residents and a visitor reportedly have died after being infected with the virus at the Life Care Center nursing home in Kirkland, Wash., a suburb of Seattle. An additional 70 employees have reported symptoms consistent with the disease.

Nationwide, administrators of nursing homes, assisted living facilities and other care centers for elders and disabled people are implementing sweeping new protocols to respond to what public health leaders say could become a pandemic without aggressive intervention. The measures include restrictions on visitation and the screening of vendors.

Kristin Knapp, a spokeswoman for the Florida Health Care Association, said members of the long-term care industry association are treating the coronavirus threat with the same urgency as they would a hurricane. Nursing home administrators have held at least two conference calls in recent weeks with Gov. Ron DeSantis, Florida Surgeon General Scott Rivkees and Agency for Health Care Administration Secretary Mary Mayhew.

Leaders have reviewed “fundamental infection control procedures” and Centers for Disease Control and Prevention guidelines, as well as guidance on staff retraining and visitor screening, Knapp said. Visitors are being queried about recent travel — especially overseas — and travel aboard cruise ships during the past two weeks. Visitors displaying worrisome symptoms are being kept away.

Mindful that long-term care residents can feel isolated, and may be separated from spouses and other family members, homes have encouraged residents to communicate through video teleconference applications, such as Skype or Zoom. “We want to try to help [residents] visit loved ones,” said Knapp, whose group represents about 550 of the state’s roughly 695 nursing homes.

“One thing we are stressing: Like hurricanes, all emergencies are local,” said Knapp, who added that members are encouraged to stay in touch with local health department leaders and coordinate information regarding supply shortages and protective equipment.

The new federal rules allow inspectors to continue performing several oversight roles, such as investigating the most severe allegations — so called “immediate jeopardy” complaints — as well as allegations of poor infection control, inspections of new facilities, and inspections that are part of ongoing agency enforcement.

But the reduction in inspection activities will virtually eliminate the investigation of most non-emergency nursing home complaints, the greatest source of information leading to enforcement. Complaints can originate anywhere, though typically they involve the spouses, children and other loved ones of nursing home residents.

Brian Lee, who heads the advocacy group Families for Better Care, and is a former long-term care ombudsman in Florida, said 65 percent of the deficiencies cited at nursing homes that involve the “actual harm” of a resident began with a complaint. Among “immediate jeopardy” allegations, 82 percent of citations resulted from a complaint, Lee said.

“This is the equivalent of throwing out the baby, the bathwater — and the entire bathtub along with it,” Lee said of the new rules. “This is a real threat to the safety of residents.

“This is something the nursing home industry has sought to achieve for decades — through lobbying, through millions of dollars in campaign contributions,” Lee said. “And coronavirus came in and achieved all of that overnight.”

The suspension of enforcement activities comes at a time of scaled-back federal regulation of long-term-care facilities across the board. In 2017, shortly after President Donald Trump took office, his administration announced it would relax several Obama-era protections for nursing home residents. The rollbacks decreased the use of fines for activities that endanger patients, eliminated the need to have basic care plans for new residents and reversed an Obama rule that forbade homes from requiring residents to sign arbitration agreements — pledging to forgo a lawsuit in exchange for having an arbiter hear a complaint and issue a ruling — prior to admission.

The CMS notice urged inspectors to focus their surveys on facility deficiencies such as improper procedures for limiting transmission of infectious diseases, lack of knowledge among staff for preventing transmission of infectious diseases, improper use of personal protective equipment or inadequate hand hygiene by staff, laundry services and other high-risk environmental cleaning issues.

Inspectors also are urged to consider how a facility manages influenza and pneumococcal programs, such as immunizations.

When state inspectors confirm or presume that a hospital patient or nursing home resident has been infected by the coronavirus, federal regulators want them to notify a CMS regional office of the facility and the date the patient was confirmed or presumed to have COVID-19, the disease caused by the coronavirus.

If conditions do not present an immediate jeopardy to patients or residents, then desk audits — which don’t involve traveling to the facility — will be performed, according to the CMS notice. Inspections may be authorized once all active or suspected cases of COVID-19 have been cleared from the location.

The CMS notice advises state agencies to limit surveys to one or two inspectors for “an abbreviated complaint survey” focused on the coronavirus, and to exclude inspectors who are ill or have underlying health conditions.

Florida health regulators reported they are working together to alert providers and stakeholder groups of best practices. The Agency for Health Care Administration’s “top priority is the health and safety of residents and patients in the facilities we regulate,” AHCA spokeswoman Katie Strickland said in an email. Agencies have been regularly updating administrators at nursing homes and assisted-living facilities, as well as their industry groups.

As of Tuesday morning, the United States’ case count is “somewhere close to almost 700 confirmed and presumed cases,” said Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, during the AARP conference call. Messonnier said all cases originate from 38 jurisdictions, including Washington, DC.

“We should expect those case counts to go up,” she said. “Globally we continue to see large increases in disease.”

Florida’s health department has reported 20 known COVID-19 cases with state ties, including four in Broward County. In addition to the 14 people diagnosed in Florida, five were Floridians “repatriated” — perhaps from abroad — or diagnosed and isolated in another state. One non-Florida resident also tested positive.

As of 9 p.m. Monday, the state said it had received 140 negative test results and that 115 tests were still pending. That means, including the positive cases, the state has run at least 270 novel coronavirus tests since public health labs in Miami, Tampa and Jacksonville began testing on Feb. 29.

Florida has a 24/7 hotline set up for people who think they might be suffering from COVID-19. The phone number is 866-779-6121, or you can email COVID-19@flhealth.gov.

Samantha Gross of the Miami Herald/Tampa Bay Times Tallahassee bureau contributed to this report.