While Recognizing Dangers, California Tells Nursing Homes to Prepare for COVID-19 Patients [UPDATED]

The California Department of Public Health (CDPH) issued recommendations for skilled nursing facilities on preparing for COVID-19 — and told them to prepare to receive and care for residents with suspected or confirmed COVID-19 infections.

The all-facilities letter (AFL) sent on March 19 tells SNFs to prepare for COVID-19, the disease caused by the novel coronavirus that emerged late last year. While noting that “elderly persons and those with chronic medical conditions may be at higher risk for severe illness and death from COVID-19,” it directs California SNFs to be ready to take in patients that are confirmed or suspected of having the disease.

MarketWatch first reported on the letter.

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Specifically, according to the letter, SNFs in California should:

  1. Prevent introduction of COVID-19 into their facility;
  2. Detect COVID-19 in their facility;
  3. Prepare to receive residents with suspected or confirmed COVID-19 infection;
  4. Prepare to care for residents with suspected or confirmed COVID-19 infection; and
  5. Prevent spread of COVID-19 within their facility.

Concerns about bed capacity in the hospital setting are looming as the number of coronavirus cases across the country spikes. Seema Verma, the administrator of the Centers for Medicare & Medicaid Services (CMS), noted that the agency’s decision to waive the three-day stay rule for Medicare coverage of a SNF stay was designed to ease stress on hospitals.

But while hospital capacity amid a surge of COVID-19 patients is a concern, the risks to those who live in SNFs are significant, as even the ALF letter notes.

For the California Association of Health Facilities (CAHF), the American Health Care Association affiliate in the Golden State, the dangers that the coronavirus poses to the SNF population are too great to make admitting COVID-19 patients a possibility.

“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 sent to Skilled Nursing News via e-mail.

The CAHF has “urged the state to look at alternate care sites,” including closed health care facilities that could be reopened in case of a surge of coronavirus patients, she added.

Emergency 1135 Medicaid waivers granted to Washington state and Florida, for instance, allow nursing facilities to continue to receive reimbursements for care provided at alternate sites — including facilities not licensed for care — in the event of an evacuation.

SNN asked the CDPH why it expects SNFs will have to take in COVID-19 patients; whether all SNFs in California should be prepared to deal with such patients; under what conditions a COVID-19 patient can be safely transferred to the SNF setting; and when SNFs should expect to receive such patients.

The CDPH said in response that its guidance in the letter was for SNFs to be prepared to potentially start receiving patients who may require lower-level care, not acute care.

“Hospitals are required to properly care for individuals and discharge them to the appropriate levels of care when a patient is ready for release,” the CDPH said. “This includes patients who may have entered with the need for acute care as a result of COVID-19, and are ready to be released.”

‘We Don’t Want to Have an Increase in Deaths’

Even before the COVID-19 outbreak, SNFs have struggled with infection control and prevention, and CMS pledged to crack down by focusing inspections on this issue at the beginning of the month.

At the Kirkland, Wash.-based SNF a COVID-19 outbreak that ravaged residents — largely because of staff working while sick and the sharing of staff members between multiple facilities — resulted in a death toll of 23 as of March 9, according to a report from the Centers for Disease Control and Prevention (CDC).

For Michael Wasserman, the president of the California Association of Long Term Care Medicine and a geriatrician for decades, the ALF issued March 19 “scared the living daylights out of me” because of what happened at the Kirkland facility.

The California Association of Long Term Care Medicine is the state affiliation of AMDA, the Society for Post-Acute and Long-Term Care Medicine.

“We don’t want to have an increase in deaths,” Wasserman told SNN.

Angie Roberson, the president of the American Case Management Association and the director of case management at the Spartanburg Regional Healthcare System in Spartanburg, S.C., told SNN in a recent podcast interview that any patient in the acute care setting that is infectious would not be introduced to a SNF population.

“From a case management perspective, we would be working with our infection prevention staff and those teams of physicians to ensure that our patients are being isolated appropriately in care, the care and treatment that they’re being provided, and that we’re not moving them until they’re no longer a threat to the other community,” she said in the interview, which was recorded March 10.

The CDPH letter advises SNFs in California to “institute the appropriate precautions to prevent spread of infection to [health care personnel] and other patients” by ensuring the staff know “standard and transmission-based precautions.”

It also recommended ensuring the facility “has adequate supply of facemasks, N95 respirators, face shields or goggles for eye protection, gowns and gloves; place supplies in all areas where patient care is provided.”

The letter also called for SNFs to ensure that facilities have “adequate supply of alcohol-based hand rub and that it is easily accessible in every resident room.”

But those supplies are already falling low for health care providers all over the U.S. across the care continuum. In a recent call with reporters, the American Health Care Association — which represents more than 14,000 individual nursing homes and senior living communities — predicted that without changes, 20% of the nursing homes in the country will run out of masks and gowns by next week, with a further 20% exhausting their supplies by the following week.

“There just isn’t enough out there in the existing stockpiles and supply, and we have done some of our own surveys that suggest really over the next week to two weeks, we’re going to see that curve go up dramatically,” AHCA chief medical officer David Gifford said.

“Our members are struggling to obtain personal protective equipment, and without proper protection, any introduction of new patients with the coronavirus would compromise resident and employee safety.”

As a result, Wasserman told SNN that he was working to contact California Gov. Gavin Newsom to try to push for a change to this directive.

“He’s getting bad information right now, whatever’s driving this,” Wasserman said of the CDPH letter. “He’s doing a lot of great things, but when it comes to direction on nursing homes, he’s getting bad information.”

UPDATE, Monday, March 23: The California Department of Public Health released the COVID-19 Health Care System Mitigation Playbook, which noted that COVID-19 patients should not be sent to long-term care facilities without consulting the local health department.

The state also added that as it will be necessary to designate facilities as receiver sites for such patients, regional health care systems need to begin planning for “this community-level cohorting now.” CDPH additionally revised the All-Facilities letter discussed in this story to make changes to guidance regarding asymptomatic health care personnel.

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