Amid Shortages, Using PPE According to CMS Guidelines Could Cost Nursing Homes $10K a Day — Or More

Updated guidelines on the use of personal protective equipment (PPE) are causing major headaches for health care providers across the continuum, as both acute and post-acute care settings grapple with supply shortages and a surge in cases of COVID-19.

Those headaches include grappling with significant shortages of equipment in the face of the highly contagious coronavirus — as well as some serious associated financial strains, particularly for cash-strapped skilled nursing operators.

Leaders at multiple senior living organizations have been sounding the alarm about the issues stemming from the shortages of PPE for some time. As early as the end of February, there were concerns about the supply chain for SNFs if COVID-19 were to gain a major foothold in the U.S.


A month later, many of those concerns are coming to fruition. In mid-March, the American Health Care Association (AHCA) predicted that 20% of nursing homes in the U.S. would run out of masks and gowns in a week’s time. Now, at the beginning of April, providers across the country are struggling to keep enough PPE In stock for their staff.

The federal government last week mandated expanded use of PPE, with the Centers for Medicare & Medicaid Services (CMS) calling for the blanket use of face masks as long as an emergency declaration was in effect — as well as full PPE in all buildings with evidence of COVID-19 transmission.

For the average 100-bed SNF, following these new guidelines in the long-term care setting would lead to increased costs of $10,000 per day as staff follow the directive to “wear full PPE for the care of all residents irrespective of COVID-19 diagnosis or symptoms,” according to an analysis announced by the Society for Healthcare Organization Procurement Professionals (SHOPP) that was released on Monday.


The analysis was conducted by Michael Greenfield, the CEO of Prime Source Healthcare Solutions and one of the cofounders of SHOPP, and Faygee Morgenshtern of People Powered Nursing.

LeadingAge, which represents non-profit senior living and skilled nursing providers, stressed the issue of PPE in responding the April 2 guidance from CMS.

“We have said, and we repeat again, that our providers do not have sufficient supplies of personal protective equipment (PPE) and other resources to adequately protect staff and to ensure the well-being of residents,” president and CEO Katie Smith Sloan said in the statement.

In an April 3 e-mail to SNN, Greenfield broke it down in terms of the equipment an average facility with a census of 100 would need, should it have “one active COVID patient.”

According to Greenfield, the minimum amount of PPE items per day would be:

  • 100 N95 facemasks (reusable)
  • 100 gowns x 100
  • 200 gloves x 100
  • 100 face shields (reusable)
  • 100 8-ounce hand sanitizers x 3

“The biggest challenge is that people have the virus [in their facilities], but they don’t have funds, they don’t have the support, and they don’t have the supplies,” Greenfield told SNN in a phone interview on April 3.

What’s important to note is how fluid that increased cost of $10,000 is, Ari Stawis, director of professional services and development at the consulting firm Zimmet Healthcare Services Group, told SNN. The New Jersey-based consulting firm’s leadership was involved with SHOPP’s founding.

“The dollar amount associated with it, that was as of that day,” he told SNN on April 6. “But things are ever-changing.”

That fluid situation extends to the guidelines from CMS, the language of which can sometimes be challenging for providers to interpret, both Stawis and Greenfield noted. It can also be hard to know which guidelines to follow, Stawis said, which has led to confusion for providers as state and federal guidelines keep evolving, sometimes making it hard to understand which employees need equipment and which do not.

Because the need for PPE is so acute, providers are combing every possible source they can for new product, Greenfield told SNN in the April 3 interview. Many times, a distributor will indicate they have PPE product, only to clarify on the phone that the product is “coming in.”

“Quite frankly, the reality of getting products internationally is: Items are being stuck at the border, customs are backed up days and days, and governments seizing products,” Greenfield said.

But because SNFs are in such need of PPE, there are many operators “taking major, major risks” and putting up money for international distribution — risks that he estimated pay off at least 50% of the time that he’s seen.

But the risk is significant. First, they have to be able to vet a proper manufacturing and distribution channel, which is not easy to do; in fact, this process used to involve months of work, though necessity has forced that process to speed up, Greenfield said.

Next they have to place the order, and since individual nursing homes might not need PPE in the bulk required for the orders, operators have to gather together to meet minimum order requirements from outside the U.S.

Then they must put up “major, major” deposits: Under normal circumstances, 25% of an order is a standard deposit, but competitors in other countries are willing to put up 100% deposits.

That’s led Prime to vet manufacturers that have strong relationships with U.S. distributors, and who are willing to send products to the U.S. first; through these relationships, they will allow a 25% deposit, Greenfield noted. But the landed cost, or the total price of a product or shipment when it reaches a buyer, is still “five times more than it was a month ago,” he said on April 3.

Assuming everything goes smoothly from order to the PPE reaching the country safely, the turnaround time is a minimum of two weeks, and “the cost of the product is still astronomical,” he said.

But that said, operators coming together and placing international orders is still a better first step than trying to chase down product that’s theoretically on the ground in the U.S, Greenfield said.

“They use reliable manufacturing organizations that are FDA-certified and approved, and they use delivery companies that are very well-known. And then they hold their breath,” he told SNN. “But I would say that’s the first step I would recommend for operators to do.”

Of course, the challenge is that product arriving in two weeks’ time does not help a facility that has an outbreak in that interval — and outbreaks in nursing homes in the U.S. have been growing by the day. Facilities dealing with large, reputable distributors are in a better position, Greenfield said, but facilities that aren’t using those distributors — or even those that are but are behind in allocation — have to go through channels that are unknown. As a result, vetting vendors has become one of Prime Source’s major tasks.

In the meantime, providers are still paying significantly more for PPE than they ever have in the past. Though the number fluctuates from day to day depending on market demand, some operators told SHOPP that they used to spend between $20,000 to $25,000 per year on PPE items, Stawis told SNN in an April 6 email.

Now, those operators [are spending close to $100,000 per month, he said.

In addition, PPE is not an expense for which SNFs can typically receive reimbursement, Stawis told SNN, though it might depend on whether a SNF is in a state that reimburses based on cost or case mix index. And the $2 trillion stimulus bill that passed in late March largely left SNFs out of the relief for post-acute care.

As a result, SHOPP is trying to advocate for some of the funds to be sent to the SNF setting, specifically to help them alleviate their PPE costs — especially given that SNFs in many states do not have the option to refuse patients based on their COVID-19 status.

In addition to the PPE expenses, staffing poses a significant concern, particularly amid new CMS guidance requiring operators to assign specific staff members to groups of residents. If a facility has a 1:10 staffing ratio of nurse to patients, and four patients arrive with a diagnosis of COVID-19, then one nurse cannot take care of four COVID-19 patients and six patients without the virus. That means staffing ratios have to change, which in turn means having to creatively use the layout of a given building.

“We want to be a team player, but there’s only so much we can do without being reimbursed for it,” Stawis said.

Greenfield put it in starker terms, especially given the issue of labor in the time of COVID-19.

“The government needs to step up their programs to giving these nursing homes the funding they need,” he told SNN. “Without it? they will not be able to survive. This is a life-or-death situation. This is not a joke. This is not asking the government for assistance and hoping it comes through. This is: If the government does not assist, nothing will change, and unfortunately people will die.”

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