Even Strictest Nursing Home Guidance Meaningless Without Two Things: COVID-19 Tests and PPE

Over the last month, we’ve seen entire years’ worth of rulemaking around nursing home safety, as both the federal government and individual states respond to the ongoing COVID-19 crisis.

These efforts have taken many forms. At the federal level, the Centers for Medicare & Medicaid Services (CMS) has largely focused on removing regulatory barriers on an emergency basis, encouraging skilled nursing facility operators and staff to take any steps they can to provide uninterrupted care — whether that’s performing a doctor’s visit over Skype without fear of a HIPAA violation, or making it easier for desperately needed frontline staff to cross state lines.

To CMS’s credit, the agency began emphasizing infection-control inspections in nursing homes well before the concept of “social distancing” became our new daily reality, suspending all non-emergency surveys to focus on infection on March 4 and providing a new set of standards based on lessons learned in the deadly outbreak at a facility in Kirkland, Wash. late last month.


States, meanwhile, led the way in encouraging operators to develop coronavirus-specific facilities, with Massachusetts in particular pioneering the practice of transferring nursing home residents into segregated COVID-19 properties — known in the infectious disease world as “cohorting.” CMS followed suit late this week by making cohorting a nationwide mandate.

All of these steps have nursing home residents’ best interests at heart, and many were developed with direct input from the industry itself. But unfortunately, they’re largely meaningless without two things that the federal and state governments need to start sending to nursing homes now: COVID-19 testing kits and personal protective equipment (PPE).

By now, shortages of both have made national headlines, with deeply disturbing stories of practitioners forced to use a variety of non-standard items — from garbage bags to hand-sewn face masks to, in one particularly absurd case, a New York Yankees-branded rain poncho — when their supplies of true PPE ran low.


Access to testing remains scattershot, and CMS only this week introduced emergency guidance allowing laboratories to receive payment from Medicare for providing COVID-19 tests in nursing facilities and private homes.

It may seem obvious, but it’s worth emphasizing: Nursing home operators simply cannot sufficiently follow the guidelines, and keep their residents completely safe, unless they have all of the PPE they need, and they know exactly who does and who does not have the virus.

What is a building administrator supposed to do when the state orders her to begin sending residents with COVID-19 to a special dedicated facility in her county if she can’t test everyone immediately — or if her hospital partners can’t test everyone prior to discharge?

What are frontline caregivers supposed to do when they read updated CMS guidance requiring them to wear PPE at all times because of COVID-19 transmission in their facility, but supplies are running low and their vendors aren’t sure when more N95 masks and gowns will be coming?

What is a chief medical officer supposed to do when she knows that staff shouldn’t come to work if they even suspect they have the virus, but they can’t get tested — and she knows that they can spread COVID-19 even without displaying any symptoms?

The Centers for Disease Control & Prevention (CDC) determined that 57% of residents at a nursing facility in Washington state who tested positive for the virus had no symptoms at the time their tests were taken.

So when the federal government tells all nursing homes, as it did late Thursday, to screen everyone coming into a building for symptoms such as fever and cough, it’s a bit of common-sense wisdom that most good operators have been doing for weeks now. But it doesn’t replace the certainty of quick, accurate, and covered COVID-19 testing for everyone who works in the post-acute and long-term care space — and the vulnerable people in their care.

As we’ve learned all too tragically, there’s only so much that preventative measures such as visitation bans, symptom checks, and tighter infection-control protocols can accomplish.

It’s not enough, as CMS said Thursday night, for “state and local leaders to consider the needs of long-term care facilities with respect to supplies of PPE and COVID-19 tests.”

The federal government must take all steps necessary to ramp up production of PPE and send it to our nation’s nursing homes with the help of state and local governments. With eye-popping unemployment numbers and demand for all kinds of consumer goods flagging amid economic uncertainty, it’s not difficult to imagine a win-win situation where Congress and CMS fund the emergency manufacture of PPE at idle plants across the country — putting people to work and protecting the vulnerable at the same time.

CMS must also make access to COVID-19 testing a baseline part of each nursing home’s day-to-day operations so that leaders and caregivers can comply with the wave of new regulations, and make the right choices to keep our frail elders safe.

The people on the front lines of the COVID-19 crisis have been doing heroic work, and will continue to perform their duties with strength and grace long after the immediate danger passes. But they can’t do it alone.

They need the two most effective weapons in their toolkit — plentiful PPE and frequent testing — to fight back the tide. The government needs to give it to them now.