The COVID-19 pandemic revealed deep cracks in the supply chain of personal protective equipment (PPE) for all health care providers, but nursing homes — which under normal circumstances do not require nearly as much as they do now — have felt particular strain.

In northern New Jersey, a non-profit senior care operator has been forced to rely on a nameless man leaders have dubbed “Parking Lot Guy” for its most reliable source of masks and gowns. Farther east on Long Island, a CEO found himself approving a check for $150,000 for PPE with prices in the dollars per unit, as opposed to the cent price points of the past.

And in Texas, leaders at HMG Healthcare LLC reached into their own pockets to the tune of $750,000, CEO and managing partner Derek Prince tells SNN.

“That’s come from our four partners, personally and on our credit cards — just putting them on those and then hoping, as things continue to work out, that we’ll be reimbursed,” Prince said.

SNN spoke with Prince last week to learn how The Woodlands, Texas-based chain of 29 post-acute and long-term care facilities has weathered the COVID-19 storm so far. Like many other leaders across the country, Prince expressed frustration about conflicting edicts from various levels of government — while also emphasizing that he’s not interested in playing the blame game with any stakeholder until the crisis passes.

Please note that this interview was conducted on Tuesday, May 5, and thus reflects what was known about COVID-19 at that particular time.

Are you a leader in post-acute and long-term care with a story to tell from the ground? Drop us a line at [email protected]. As the crisis continues, SNN wants to highlight the industry’s struggles, successes, and visions for future change.

What are you seeing on the ground?

The biggest thing that we need help with is on testing. We have 29 post-acute care facilities between Texas and Kansas, our largest footprint being in Texas, and we have requested on multiple occasions assistance from both county and state authorities on helping get us testing for both our resident populations and our staff populations. Unfortunately, even though with the help recently — the CDC making skilled nursing facilities a priority — that only covers symptomatic patients and staff members. It doesn’t do anything from a preventative standpoint; It’s almost like reacting after the fact.

We’ve kind of circumvented that. Even though we’ve continued to ask, and we’ve continued to be told no, we’ve now gone out on our own. We’ve secured test kits for our resident population and for our staff population, and we’re actually started this week — we are now testing 100% of our staff members and our resident populations to get baseline information on all of them.

Then we’ll do biweekly testing for all of our employees as the economy begins to ramp back up, because we’re scared that there’s going to be too many opportunities for encounters. We’ve got to keep that monitoring. We’ve got it set up to continue monitoring biweekly for the next six months; we’ll have to see how everything turns out.

Then once we get baseline testing on our resident population, we more or less control that population. If they are a positive result, we’ll obviously test to see if they’ve made it through when they become asymptomatic after the fact, and make sure they’ve actually recovered. There will be times that we’ll continually test our patient population.

We’ve just taken that on as an organization because from what we’ve seen, there’s been so many asymptomatic employees and residents. The only way we feel that we can get ahead of it is testing. Unfortunately, we’re not getting that assistance from any of the local, state, or federal entities.

You’re certainly not the first operator to tell me about wanting to get tests but not being able to get nearly as many as needed.

It’s extremely frustrating. I want to make sure that I convey to you: I don’t want to blame anybody, even though I’m frustrated with the way that this has been handled. It’s certainly easy, and we are at the forefront of being blamed right now. Everybody is casting shame and blame and vilifying all of the people — and specifically nursing homes.

We can Monday-morning quarterback this after this is all said and done. We just view it as: Let’s just try to solve the problem currently. Let’s make it through it. And then let’s all get together as stakeholders, legislators, independent bodies and figure out what we can do — what we could have done better after the fact.

But this shaming and blaming game that everybody’s playing right now, I don’t see the upside. We just need to try to come up with solutions, implement those solutions, work together, share our information, and let’s get ahead of this. Otherwise, if we just keep pointing fingers, this is not going to go anywhere very fast.

You mention stakeholders — the federal government wants a lot of them for its upcoming task force. What would you suggest if you had a seat at that table?

One, I would go back to what we talked about: testing. I think testing is of paramount importance. We test everyone, and we keep testing everyone until we get a vaccination. I certainly understand why everyone needs to reopen the economy. But all that does is open up more possibilities for our employees — even if they’re the best of employees and only patronize essential businesses — [to] increase their opportunity to come in contact with somebody, or somebody touching something else.

If they were to just go to grocery stores, gas stations, things of that nature, it makes me extremely anxious. So again, if I was on that task force, I would continue to push testing, testing, testing.

As we go further out … I think that the reaction was somewhat slow — by everyone. Again, I’m not blaming anyone, but whether that be CMS at the top, whether that be state and local governments — here in Texas, in particular, the county health departments and the county judges. Because they acted so slow on the front end of this situation, I think now while they’re trying to catch up and be overly helpful, they’re not getting us what we need in the way of testing, funding — things that truly matter at this moment. We did receive the tranche one and tranche two [from the federal government]; it’s still not even close to enough to cover the testing, the PPE supplies, things of that nature.

So while they’re not getting the things that we absolutely need, they’re trying to come forward with all these different strike forces and task forces — and unfortunately, they’re not coordinated. We’re having to report one set of information and data to a local health authority. We’re having to send another thing to DHES here in the state, which is the department of health … and now, as of this Friday, we’ve got to go through the CDC portal and report there.

If I was on it, I would try to streamline it because all of these task forces, while well-meaning, they’re asking for duplicative information, and we’re providing that over and over — and all that does is take away from the actual patient care. When we’re under a model, between quarantining staff and just the situation as a whole and the staffing shortages that we’re already experiencing, it just pulls away from actually delivering patient care under this major crisis situation.

I’ve heard similar things from operators with larger, multi-state footprints — it’s hard to keep up with the varying rules.

It’s funny you mention that — it is nice that we’re only in two states. I will speak specifically to Texas. There’s a lot of power on the front end that was given to our county judges by Governor Abbott, that allowed local counties to make certain rules. We’ve got certain rules that we have to apply here in Harris County and Houston; we’ve got another set of rules that we have to abide by in Dallas County. Montgomery County has different [rules].

So even though we’re not in multiple states, the way that Texas has handled it, it’s almost the same situation, because county judges are being allowed to do certain things and put certain protocols in place. It’s just been maddening.

How are you managing the financial aspect of the pandemic? I’ve spoken to operators that have spent hundreds of thousands of dollars for testing and PPE.

We had cash on hand, but in the last 60 days, we’ve purchased an additional $750,000 in excess PPE. On the front end, we weren’t able to find it, and we were dealing with some sketchy characters.

Obviously, we’ve gotten our supply line set up, but we’ve purchased almost $750,000 — and that’s come from our four partners, personally and on our credit cards, just putting them on those and then hoping, as things continue to work out, that we’ll be reimbursed. I don’t fear that we won’t get reimbursement, but as a mode of financing, we’re taking the burden on individually as owner-operators, our four partners here. We’re bearing that load right now.

What’s the impact on census, and where has the biggest strain been? Is it from a lack of admissions, or families pulling residents out?

We haven’t seen very many families pull residents out, but we have seen a massive decrease in new admissions. Overall, our census is down, May 1 from February 1, roughly … around 13% across the board, and it is just basically on the number of referrals. There’s nobody in the hospitals. The hospitals cleared out … so there’s just not anybody in the hospitals now to discharge back out to the facilities.

What’s your usual balance between post-acute and long-term care residents?

I would say about 25% of our total, across the entire portfolio, is post-acute, and then I would say 75% is long-term care, across the entire portfolio.

How have you been able to balance the needs of those two populations? This was a major source of conflict in New York, for instance, where until recently facilities couldn’t deny admissions based on COVID-19 status.

In some of our more rural buildings, we haven’t been able to do this, but I would say in roughly 90% of our portfolio, the way our buildings are set up, we were able to designate an isolation hall to where there was a specific, separate entrance. There’s specific staff, where they were not coming in contact with anybody else; everything was set up so as any new admissions or readmissions came to our buildings from the hospital, we’ve been able to put them on an isolation unit and continue to watch them there.

Now, we’ve had issues with that, because they’re not very large, obviously; we didn’t have tons of room to begin with. That goes back to our testing discussion previously — we’ve got to begin retesting some of these folks to make sure that they’re not [positive], test everybody there to make sure that we can pull these folks off of this isolation unit whenever it’s safe to, as they’re cohabitating.

That makes it extremely difficult, even with our isolation unit: When is it an appropriate time, if at all, to move them back to our general population? That comes back to the inconsistency with what we’re being told county by county. Each local county health authority has different suggestions on what we need to do, which obviously compounds our problem.

This interview has been condensed and edited for clarity.