Officials refute report expected to allege undercount in COVID-19 long-term care deaths

Michigan health officials are disputing a report that they say is expected to allege the state undercounted potentially hundreds or thousands of COVID-19 deaths of residents at long-term care facilities.

In a recent letter to the Michigan Office of the Auditor General released Tuesday, Michigan Department of Health and Human Services Director Elizabeth Hertel says the auditor general made a series of errors, including conflating death definitions, examining data from facilities not required to report deaths and using sources that are unreliable.

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While the auditor general's office declined to comment on the report, Hertel's letter indicates the state anticipates it will say the department undercounted the number of long-term care residents who died because of COVID-19 by nearly 30%.

"I continue to have serious concerns about both the methodology employed to

compare long-term care facilities’ self-reported data to death certificate data from Michigan's Electronic Death Registry System and COVID-19 case and death data from the Michigan Disease Surveillance System, as well as the conclusions you’ve drawn from this review," Hertel wrote in the letter to Auditor General Doug Ringler.

"I fear that your letter will be misinterpreted to question the work and integrity of long-term care facilities, local health departments, coroners, and other frontline workers who we rely on to report data."

At no point in her letter does Hertel actually summarize the auditor general’s broad findings. Her letter is in response to preliminary findings.

A spokeswoman with the auditor general’s office confirmed Tuesday afternoon it had finalized its review, delivering it in the form of a letter to House Oversight Committee Chairman Steven Johnson, R-Wayland. The spokeswoman declined further comment, saying the office would publicly release the results next week.

The findings are sure to fan political flames for critics of Gov. Gretchen Whitmer and her administration's COVID-19 policies for nursing homes and similar sites. Whitmer and others have repeatedly debunked allegations that Michigan residents not suffering from COVID-19 were forced to live in close proximity to infected residents.

“While I am eager to thoroughly review the full report, what has been made clear is a sizable and shocking undercount of COVID-19 deaths at long-term care facilities in Michigan," Johnson said in a statement issued late Tuesday.

"The number reported by Gov. Gretchen Whitmer’s administration was 30 percent lower than what the auditor general has found. Make no mistake — this is a large discrepancy, and the report makes that clear."

There have been 4,532 COVID-19-related deaths of residents in skilled nursing facilities in Michigan since the start of the pandemic; 1,036 deaths of residents in homes for the aged, and 648 deaths of residents in adult foster care facilities through the week of Jan. 5, according to the state's coronavirus dashboard.

The combined number of resident deaths in these three types of facilities — 6,216 — account for about 22% of Michigan’s 28,228 deaths from COVID-19.

More: COVID-19's deadly domino effect: It's killing people with other health problems, too

More: Michigan Auditor General to study long-term care facility deaths in COVID-19 pandemic

Hertel testified last year before state lawmakers, arguing Michigan did not undercount pandemic-related nursing home deaths overall but deaths at smaller long-term care facilities might have slipped through the cracks.

Hertel’s argument to the auditor general boils down to several key points. She contends:

• Auditors used a definition for a COVID-19 death at a facility that is overly broad and does not conform to federal standards.

• Facilities that are required to report provide their own data, and ensuring this information is accurate would require analyzing records from every such site in the state.

• The auditor general gleaned information from a repository called the Michigan Disease Surveillance System, a database created to perform contact tracing but ill-equipped to accurately track deaths.

• Many facilities in the state do not meet the definition of a long-term care facility as used by federal health officials and are not required to report deaths to the state. By including these deaths in their findings, the auditor general is creating a misleading picture.

The auditor’s definition for an applicable COVID-19 death at a long-term care facility appears to be Hertel’s biggest issue with the report.

"A reportable long-term care COVID-19 death is defined by the National Healthcare Safety Network as a resident who died from COVID-19 related complications and includes resident deaths in the facility, and in other locations in which the resident with COVID-19 was transferred to receive treatment," Hertel says in the letter.

"Residents not expected to return to the long-term care facility are excluded from the count. MDHHS has always required long-term care COVID-19 deaths be reported consistent with this standard set by the federal government."

She said the auditor’s report includes people who recovered from COVID-19 and then went to hospice or to live with family members before dying. It also includes residents hospitalized for something other than COVID-19, such as a bad fall, who then acquired COVID-19 after leaving their long-term care facility.

Lastly, she argues the auditor’s definition of long-term care facility is too broad. She contends state and federal regulators have a very specific definition for what constitutes a long-term care facility: only those sites that meet this definition are required to report to the state, and the state only tracks these numbers so as to provide consistent data that can be compared with other states.

“Long-term care facilities were only required to report COVID-19 deaths within the definition provided by CDC. Stating that long-term care facilities that did not report deaths in the above categories ‘underreported’ deaths is simply not accurate,” Hertel states in her letter.

Without getting into specifics in her letter, Hertel broadly says the auditor general includes deaths from facilities that should not be counted in this analysis.

Hertel previously told lawmakers about the difference between nursing homes, homes for the aged and adult foster care. Nursing homes are now required to report pandemic-related deaths, but some of the smaller facilities are not.

According to an in-home care and senior residences handout by the Michigan Attorney General’s Office, independent living communities are designed for independent seniors and are typically apartments, condominiums, or free-standing homes. They don’t have to be licensed, and residents who need or want help with personal care can hire a nonmedical agency to provide those services.

In assisted living communities, a resident may receive help for a range of daily activities, such as personal care, meals, and medication management. Some of them, such as adult foster care and homes for the aged, are licensed by the state’s Department of Licensing and Regulatory Affairs.

Continuing care centers include independent and assisted living, memory care and nursing home care in one location, and residents can stay on one campus as their housing needs change over time, according to the handout.

And it states that a nursing home is a nursing care facility, including a county medical care facility, that provides organized nursing care and medical treatment to seven or more unrelated people suffering or recovering from illness, injury or infirmity. They can be for short-term or long-term care. Not all of them provide skilled nursing care, which is certified by Medicare or Medicaid, according to the handout.

Hertel and state health officials appear to allege the auditor general inappropriately took data from some of these facilities for their findings.

Referencing data from the auditor's preliminary findings, Hertel says almost half of the roughly 30% of underreported deaths auditors found should be attributed to facilities that are not required to report deaths to state or federal officials.

"The narrative that follows could note that an additional 1,036 deaths were identified when your team looked across all long-term care facilities rather than limiting the scope to facilities subject to state and/or federal reporting requirements," Hertel suggests in her letter.

The anticipated findings comes months after the auditor general announced it would review how the state collected data on COVID-19 deaths. Johnson said his committee will work through the data discrepancies.

"There is frankly a lot to answer for, and our legislative panel will be working to get those answers," Johnson said.

It was also prompted more broadly by an outcry from Republicans lawmakers and others who've noted ongoing questions about pandemic-related deaths and substantial problems uncovered in other states resulting in many more deaths than previously known, such as in New York.

Almost since the start of the pandemic, Republicans have accused Whitmer and her administration of forcing elderly Michiganders to live in long-term care facilities with others who had COVID-19.

More: What we know about the impact of Whitmer’s nursing home policies

More: Feds won't investigate Whitmer, Michigan nursing homes despite data request under Trump

Whitmer issued an executive order in April 2020 that required nursing homes with available capacity to create a dedicated unit to isolate residents with COVID-19 and accept COVID-19 patients discharged from hospitals. It also designated some nursing homes to serve as "regional hubs" to accept infected residents from facilities that couldn’t safely isolate them.

Melissa Samuel, president of the Health Care Association of Michigan, a trade association that represents Michigan’s long-term health care providers, previously told the Free Press that the requirement that non-hub facilities accept COVID-19 patients was never fully implemented,

In October, auditors issued preliminary findings that showed they'd found 822 COVID-19 deaths that the state apparently missed. But the reviewers determined this was not a significant number, attributing it to spelling mistakes in reports submitted by local agencies, a time lag in updated death records and changing reporting requirements driven by revised guidance from federal health officials.

Reporter Clara Hendrickson contributed to this report.

Contact Dave Boucher: dboucher@freepress.com or 313-938-4591. Follow him on Twitter @Dave_Boucher1.

This article originally appeared on Detroit Free Press: Officials dispute report on COVID-19 deaths at long-term care facilities