As COVID-19 Surges, Lack of Tests Complicates Nursing Homes’ Decision to Admit or Deny

The danger that COVID-19 poses to residents in the skilled nursing setting was well-documented in the fallout from an outbreak in a facility in the state of Washington.

But as cases mount and hospital beds fill up, health officials across the country are starting to indicate that SNFs need to be ready to take patients who require post-acute care — possibly even if they have a confirmed or suspected diagnosis of the disease.

But there are numerous factors that go into that decision, and states are taking different approaches. SNN reached out to several provider organizations and state health departments to determine where and when operators can expect to see a push to accept COVID-19 patients.

New York Bans SNFs from Requiring COVID-19 Test

In New York, SNFs are already taking in patients with COVID-19 who have improved to the point that they need post-acute care rather than a hospital stay, using guidelines issued by their state health departments and associations. New York was reporting 30,811 confirmed cases as of March 25.

“Those admissions are happening,” Stephen Hanse, the president and CEO of the New York State Health Facilities Association (NYSHFA), told Skilled Nursing News in a March 24 interview.

Specifically, they are occurring in New York City, Nassau and Suffolk counties on Long Island, in the Hudson Valley, in Erie and Niagara counties in the western part of the state, and in Rochester and Monroe counties — “the more populated areas,” Hanse said.

But on March 25, the New York Department of Health (DOH) issued an advisory to nursing home administrators, directors of nursing, and hospital discharge planners telling them that no nursing home resident should be denied admission or readmission to the nursing home “solely based on a confirmed or suspected diagnosis of COVID-19.”

“[Nursing homes] are prohibited from requiring a hospitalized resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission,” the advisory reads.

That is “tremendously problematic” for SNFs in New York, given the shortages of personal protective equipment (PPE) and the staffing challenges — especially for those facilities that don’t have infected residents right now, Hanse told SNN on Thursday, March 26.

“We have significant PPE issues, we have staffing issues, and then we have facilities that have no residents right now that are infected with COVID-19,” he said Thursday.

In addition, though the state of New York performs a daily survey of individuals in nursing homes to determine the number of positive COVID-19 tests “and things of that nature,” the state is keeping it confidential “for internal procedures and policies only,” Hanse said in the March 24 interview.

He added he has requested that information, though as yet, he has not heard of any facilities being swamped by the virus.

The New York DOH wants infected residents to be cohorted, and many owners in New York with multiple buildings want to designate certain homes for COVID-19 patients, while moving other uninfected residents elsewhere, Hanse said in the March 26 interview — but the DOH has not waived the transfer or discharge requirements for nursing homes.

“As the hospitals are trying to push people into nursing homes and potentially risking expanding the spread of COVID-19, they’re not waiving the transfer or discharge requirements [for nursing homes],” Hanse told SNN on Thursday. “If they were to waive those, we could bring COVID residents into one building and cohort.”

The New York DOH told SNN in a statement that protecting the state’s nursing home population is a priority.

“The Department continues to issue updated guidance for nursing homes regarding testing, visitation, staffing, readmission, admission, infection control and protecting the health and rights of our most vulnerable population,” a DOH spokeswoman said in a statement provided to SNN via email.

SNFs should start the process of creating separate wings, units, or floors immediately, according to guidance released March 20 by the American Health Care Association (AHCA), which represents more than 13,500 SNFs and assisted living facilities.

AHCA noted that state public health officials could issue state or regional guidance that overrides the association’s advice for accepting coronavirus patients, but provided a list of the factors to consider: whether a SNF already has COVID-19-positive patients, the prevalence of the disease in the surrounding area, the hospital’s capacity, and the ability of the SNF to manage COVID-19 patients, whether suspected or confirmed.

For accepting hospital admissions when a SNF has no COVID-19 cases, AHCA listed several recommendations for patients that were negative or had no history of the illness, patients whose COVID-19 status was unknown, patients who tested positive for or were suspected to have COVID-19, and patients who have recovered.

Patients who have recovered — and ideally have one negative test for COVID-19 — can be admitted with some work on the part of a SNF without COVID-19 cases, such as monitoring their symptoms and limiting their contact with other residents, AHCA said in its guidance.

But there was one scenario in the case of a COVID-free SNF where AHCA adamantly warned against admission: that of a patient testing positive or being suspected of COVID-19 in the hospital.

That scenario is one that haunts Michael Wasserman, the president of the California Association of Long Term Care Medicine. The California Department of Public Health (CDPH), which has told SNFs in the Golden State to prepare to take in patients either suspected or confirmed to have COVID-19, reported as of March 24 that the state had 2,535 confirmed cases — though local media outlets Thursday were reporting more than 3,000 cases.

“We don’t want to have an increase in deaths,” he told SNN on March 20.

The California Association of Health Facilities (CAHF), the AHCA affiliate for the state, also emphasized to SNN at the time that it could not support the transfer of positive COVID-19 patients to nursing homes.

“While we recognize the reality of a possible surge of coronavirus patients, the CAHF is not in support of any plan to transfer positive COVID-19 patients to skilled nursing facilities, especially given the fatality rate in older individuals and people with serious and chronic health conditions — the very people we serve,” Deborah Pacyna, director of public affairs at CAHF, said in a statement provided March 20.

Florida to Expedite Testing for Patients Waiting on SNF Admission

The issue of patients going from the hospital to SNF has been top of mind for Florida as well, Florida Health Care Association (FHCA) director of communications Kristen Knapp told SNN in an interview on Wednesday, March 25. The emphasis for SNFs in Florida has been communication with their hospital partners, she said, with the FHCA and the Florida Hospital Association (FHA) partnering to develop communication tools to help with transferring patients from the SNF to the hospital and back again.

And in this case, the FHA has issued guidance relating to the transfer of hospitalized patients to SNFs, which among other factors recommends testing a patient for COVID-19 and getting a negative result prior to transfer to a post-acute facility.

The guidance also recommends that patients not be transferred to a post-acute care facility if they have a fever and respiratory symptoms such as shortness of breath or cough.

The issue of testing is particularly important, as the U.S. is still working to scale up its testing for COVID-19, and the shortage of test kits and supplies for them is part of the reason there is no universal testing, as Knapp observed. That makes communication with hospitals — particularly questions about whether or not an individual has been tested and the symptoms they have — very important, she told SNN.

That’s because the FHCA is hearing from hospitals that some of the test results for patients awaiting discharge are taking eight to 10 days to come back.

But the state has provided help in one key respect. Florida’s surgeon general, Scott Rivkees, told nursing homes and assisted living facilities in a recent conference call that if the test is for an individual awaiting transfer to a nursing home, the test should be sent to the Department of Health, which will expedite the test in 48 hours, Knapp told SNN.

Stabilization Top of Mind in Washington

The state of Washington, where the spread of COVID-19 throughout the Life Care Center of Kirkland played out in national headlines, has reported 2,580 confirmed cases as of March 25.

Right now, the primary concern for SNF providers is stabilizing their own populations, given concerns about multiple facilities that have reported outbreaks in the state, Robin Dale, CEO of the Washington Health Care Association (WHCA), told SNN in an interview on March 24.

Though the state has guidance similar to California’s about the need for SNFs to prepare for admitting patients suspected or confirmed to have the disease, and though WHCA issued guidance similar to AHCA’s in terms of creating a separate wing or unit, the lack of PPE is a major concern in Washington, as it is in other states, according to Dale.

But WHCA is not aware of COVID-19 patients being transferred to SNFs, at least as of the March 24 interview, Dale told SNN. The primary concern right now is what’s happening within the walls of SNFs.

“We’re not aware of [COVID-19] patients coming from the hospital to the nursing home,” he told SNN. “What we are aware of is nursing homes that have COVID patients, and some of them a lot of COVID patients, and they’re not going to the hospital. The facilities are caring for those patients and doing the best they can. It’s concerning. But everyone’s doing the best they can.”