Multi-State Nursing Home Operators Navigate Conflicting COVID-19 Rules

Skilled nursing operators across the U.S. are grappling with the challenge of caring for patients most vulnerable to COVID-19 while staying on top of a variety of state and federal guidelines. To do that without getting overwhelmed, it’s critical to have all the various components of an operation working together — and for operators with a presence in multiple states, that cooperation is of paramount importance.

That’s especially true when federal, state, and even intrastate authorities appear to be at odds with one another. For example, Indiana State Department of Health Commissioner Dr. Kristina Box had to issue an order dated April 14 to override orders from county officials that would have prevented SNFs from transferring patients with COVID-19 between counties in the state, The Indianapolis Star reported on the same day.

The order from Box cited waivers from the Centers for Medicare & Medicaid Services (CMS) designed to give extra flexibility to transfer long-term care patients. The agency indicated that the transfer waivers, which let operators shift patients within facilities or to other locations, were designed to facilitate the cohorting of COVID-19 patients.

And soon after those waivers were announced, CMS mandated that SNFs separate staff and create dedicated wings and buildings for COVID-19 patients. The federal agency will also require SNFs to report COVID-19 cases to the Centers for Disease Control and Prevention (CDC) and family members in a timely fashion, or face weekly fines.

But those changes highlight a small portion of the thicket of regulations that providers have to navigate, both on the federal and state levels — to say nothing of the guidance coming from their own associations, such as the American Health Care Association, which represents thousands of SNFs and assisted living facilities, and LeadingAge, which represents non-profit senior housing and care providers.

And as SNF providers try to cope with COVID-19, one of the biggest challenges is how disconnected other decision-makers are from the day-to-day reality of skilled nursing, according to Dr. Arif Nazir, the chief medical officer of Signature HealthCARE and the president of AMDA, the Society for Post-Acute and Long-Term Care Medicine.

“It’s been quite obvious that hospital systems really do not know that much about the nursing home environment,” he said.

COVID-19 transfers can vary

The variation in regulations on transfers between county and state officials in Indiana was a challenge for the Communicare Family of Companies, which has more than 80 SNFs in Indiana, Ohio, Missouri, Maryland, Virginia, West Virginia, and Pennsylvania.

Indiana in particular wants cohorting for COVID-19 patients, Fred Stratmann, the general counsel at Communicare, told Skilled Nursing News in an interview on April 20. The goal is to reduce risk to other SNF residents who might not have COVID-19, and to maximize infection control measures and the use of personal protective equipment (PPE), he explained.

In fact, Indiana actually established some financial incentives for buildings dedicated specifically to COVID-19, but a free-standing SNF with a COVID-19 unit — such as one of Communicare’s buildings with 26 COVID-19 residents at the time of the interview — would not be eligible, he noted.

“That transfer rule reflected what Indiana prefers,” Stratmann said. “What we’ve seen out of Maryland and Virginia is the preference to treat in place and minimize the transfers.”

That appears to be the case in Pennsylvania as well, at least partially; as of an April 15 message, the Keystone State was not looking to use SNFs as COVID-19 facilities, though it is examining options for alternative care sites, a spokesperson for the Pennsylvania Department of Health noted. SNFs still have to take new admissions and receive readmissions of current residents from the hospital who are stable, which could include patients who have had COVID-19, according to interim guidance dated March 18.

The federal government’s waivers and mandate to cohort patients do appear designed to make it as easy as possible to separate out COVID-19 patients, but that can be easier said than done, given the challenges of testing.

Massachusetts’s move to create COVID-19 SNFs, which was actually cited by CMS administrator Seema Verma as an example of the type of setup the federal government would like to see, had to change its plans dramatically when testing revealed that several residents of the facilities had the virus.

Generally, the consensus now appears to be that a SNF with no COVID-19 cases should not accept COVID-19 positive patients, Nazir said in an e-mail to SNN dated April 19. Signature has been focused on a collaborative approach in the 10 states in which it operates 111 facilities, he said.

About 30% of the Louisville, Ky.-based operator’s facilities have reported COVID-19 cases, in the states of Kentucky, Indiana, Tennessee, Georgia, Florida, and North Carolina, according to Nazir.

Signature engaged with stakeholders and policymakers at the state level, with support from AHCA and others, he said — and it hasn’t seen mandates like the directives that initially came out of New York and California requiring SNFs to take patients regardless of their COVID-19 status.

“Where hospitals kind of need to be educated and re-educated and seem to keep on forgetting is that nursing homes are not hospitals; they’re not mini-hospitals,” he told SNN in the April 20 interview. “They’re homes. Yes, there’s a small proportion of beds, a certain case-mix area where people are there for rehab, and there may be some acute-setting patients … but for the most part, nursing homes are homes for people.”

And while SNFs are working hard to provide care and bolster their infection control practices and policies, and making improvements, it’s important for states and other stakeholders to remember that they are primarily homes, he said.

Disclosure rules around COVID-19 becoming more unified

Pressure has been mounting for weeks for better public reporting of COVID-19 cases in nursing homes — even prior to CMS’ announcement that the CDC reporting would be mandatory, with NBC News, The New York Times, and USA Today among the outlets pulling state data to try and get an estimate of the loss of life in the SNF setting.

But up until CMS’s announcement, most states had been silent on SNFs reporting cases to either county health departments or families, Stratmann said, though he added Communicare was doing this reporting for families and their emergency contacts “from the get-go.”

The memo from CMS, issued April 19, emphasized that it was reinforcing a requirement that nursing homes already have to follow: namely, the reporting of “communicable diseases, health care-associated infections, and potential outbreaks to state and local health departments.”

But those requirements can vary wildly from state to state, as Stratmann noted in a followup e-mail to SNN dated April 22. In Pennsylvania, for instance, the requirement is that “outbreaks, suspected health emergencies, Anthrax, measles, etc.” be reported to state within 24 hours, while other classes of diseases need to be reported within five days. In Indiana, the times are staggered between immediate reporting — for such issues as anthrax, hepatitis A, or measles — and 72 hours for others such as AIDS or listeria.

In Maryland, while reporting mandates vary between “immediately” and one working day, anything that constitutes a public health danger has to be immediately reported to the local health department, Stratmann noted.

How to stay up to date

Signature has worked to stay on top of the different mandates and procedures coming from both CMS and the CDC through its director of infection control, which was a position it had established even before the pandemic. This director has been responsible for ensuring that guidelines on infection control and management — as well as the use of PPE and precautions — are distributed to facilities, Nazir told SNN.

This person also ensures information reaches infection preventionists and medical directors at the facility level.

And when the COVID-19 crisis began, Signature established a sort of control center, which took in the information on patients reporting COVID-19-like symptoms; the team includes Nazir, the director of infection control, the chief nursing officer, and other nurse executives at the operator. In addition, an infectious disease specialist from a local hospital serves as backup.

The team reviews each case and directs resources such as PPE, which helped prevent unnecessary burn of the equipment, he said. The group also sends information from the CDC, reviewing the site every few hours for information on properly using and extending the use of PPE.

Signature’s purchasing department has also done good work on this front, building fast connections with companies that could provide validated and credible PPE, a crucial resource amid the Wild West of the current PPE market.

For Communicare, multiple daily calls across the legal, clinical, operational, and human resources teams have become the norm, with multidiscplinary calls happening twice a day in the morning and in the evening. That might mean some team members wearing multiple hats, with auditors perhaps doing analysis for facilities to help on the clinical sides, for example, Stratmann said.

That kind of role-shifting and collaboration requires near-constant updates.

“I think we are contributing to Zoom’s record year,” Stratmann told SNN.