‘Patchwork’ Government COVID Response Put Long-Term Care Residents at Risk

While the federal government has provided sweeping guidelines for nursing homes in the fight against COVID-19, the state-level response has been wildly inconsistent, according to a new analysis from the Kaiser Family Foundation — a disconnect that may have increased the risks for vulnerable residents in certain areas.

“This state-by-state approach to the COVID-19 pandemic may result in uneven rates of illness, hospitalizations, and mortality of long-term care facility residents and staff across the country,” the Kaiser analysis found.

The Centers for Medicare & Medicaid Services (CMS) took the lead early on in the crisis, reorienting its inspection process around infection control on March 4 and issuing a ban on all non-essential visitors to nursing homes on March 14.


But the Kaiser team — led by research analyst Sarah True — pointed out that CMS’s actions amount to recommendations and not direct orders, adding that they also applied only to federally certified nursing facilities, and not assisted living or other senior care settings.

States themselves were allowed to implement their own requirements beyond CMS’s guidelines, resulting in a crazy quilt of rules regarding visits, screening of staff members, and the use of personal protective equipment (PPE) across the country.

Source: Kaiser Family Foundation

Within those state-level guidelines, Kaiser found significant variance. For instance, the majority of states only “recommended” that operators screen employees for signs of COVID-19 infection or beef up the mandatory use of PPE.


In addition, 29 states plus the District of Columbia expressly prohibited visits to nursing facilities on top of the CMS guidelines, but two had no rules at all — while six states did not regulate the comings and goings of visitors at assisted living facilities.

“The state-based patchwork regulatory approach shown in our analysis results in increased vulnerability to infection for some NF and ALF residents, depending on where they live,” Kaiser concluded. “This situation mirrors a larger national trend in COVID-19 response in which some states have taken more aggressive actions than others, while the federal government assumes a ‘backup’ role.”

Just over the last few weeks, states such as West Virginia and Maryland have implemented mandatory testing programs for nursing home residents, while others such as Illinois and Massachusetts have sent out dedicated teams of nurses — sometimes supported by members of the National Guard — to perform testing and other support work in facilities.

In one particularly controversial example of state-level guidance, officials in New York remain under fire for a mandate, issued early in the crisis, requiring operators to accept COVID-19 patients from hospitals.

Though Gov. Andrew Cuomo has insisted that the state could assist operators unable to provide contained units for coronavirus patients, both industry leaders and resident advocates have criticized the policy as dangerous and short-sighted given the rapid spread of the virus among vulnerable long-term care residents.

Those variances have also crept into states’ plans to gradually ease coronavirus restrictions as the calendar turns to May: In Washington state, an early epicenter of the COVID-19 crisis in nursing homes, the visitation ban actually expired on April 15, Kaiser noted, while Georgia and Tennessee’s emergency rules were set to elapse Thursday.

While states can extend a variety of temporary coronavirus restrictions, the lack of consistency underscores industry leaders’ concerns about states opening their doors too soon.

Mark Parkinson, president and CEO of the American Health Care Association, advised governors to think twice about lifting stay-at-home orders, pointing to infection patterns that show a correlation between community spread and the number of cases in nursing facilities.

“If states open up too early, and we have a resurgence of COVID-positive cases in the general community, this virus is so infectious and so insidious, it will make its way into long-term care facilities,” Parkinson said Wednesday.

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