As more and more states roll out aggressive COVID-19 testing plans for nursing homes, operators have claimed that they can’t meet the goals — such as a New York edict to test all staff twice per week — without significant help from the government.
Calls for mandatory testing from the White House remain only recommendations, and not orders, but Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma on Thursday indicated that more federal guidance around coronavirus tests in nursing homes may be forthcoming — while also noting that some state governors have not expressed concerns about access.
“We’re seeing a lot of work being done — FDA approving new types of tests,” Verma said on a call with reporters. “So I think that a lot of what we’re hearing is that the states have had some untapped capacity. In some of the calls that we’ve had with governors, we’ve even heard them say: ‘It’s not a supply issue. It’s a demand issue.'”
Verma conducted an on-the-record discussion about CMS’s work around COVID-19 and nursing homes with SNN and reporters from several other national outlets; the answers to the questions she fielded from the group are presented below, condensed and edited for clarity.
During her prepared remarks to begin the conversation, the administrator also pushed back on reports this week about plans to begin lifting visitation bans on nursing homes, emphasizing that any blueprint remains preliminary.
“We’re not at that point of opening up nursing homes, given where we are as a country,” Verma said. “That being said, we want to make sure that communities have a plan in place. We continue to work on our guidance.”
Verma on whether the federal government plans to provide specific support to states with aggressive testing goals:
As you know, there’s significant funding available. I’m not going to give you an exact number; it’s around $11 [billion] or $14 billion around testing that has been available through the CARES Act funding. So those are some of the dollars that are going to go out to states, and I think that they’re in the process of providing those guidelines to states in terms of how they can use those dollars. It’s possible that a state could utilize those dollars to support those efforts.
That being said, I think from the federal level, we think testing of patients and staff is a really important thing to do. From the patient level, doing a baseline survey so you can understand what’s going on in the nursing home, that helps you also be able to cohort, isolate patients as needed.
It’s also really important with staff. When staff are coming into the nursing home, what we know is that we have asymptomatic spread. Because this is such a fragile population, testing our health care workers in nursing homes is very critical. We’ve also talked about, in our guidelines, screening on a daily basis. The testing’s important because sometimes the screening wouldn’t pick it up if they were asymptomatic.
On why CMS has not formally recommended mandatory testing, as Vice President Pence suggested earlier this week:
We’re looking at that. We have guidelines; we have rulemaking. We do think it’s important, at this point, for nursing homes to do that testing, as we have said in the past — that’s very consistent with the guidelines that we’ve put out.
That’s not actually anything new. We’re continuing to assess our guidelines. That’s why you’ve been seeing, almost every couple of weeks, we’ve been putting out updates. You may see more from us on that.
On whether changing screening guidelines were based on a lack of testing, or an evolving understanding of how COVID-19 spreads:
That’s a great point, that we’re understanding new things about the virus every single day. Clearly, it’s had an impact on nursing homes that we’re very, very concerned about. In terms of the testing, what we’ve said in the past — I think we’ve always been very clear that there should be a focus on testing in nursing homes. I think what we’ve been doing with the states is helping them to identify the capacity of testing. We’re going to be hitting almost 10 million tests this week; our testing is increasing by the day.
We’re seeing a lot of work being done — FDA approving new types of tests. So I think that a lot of what we’re hearing is that the states had some untapped capacity. In some of the calls that we’ve had with governors, we’ve even heard them say: “It’s not a supply issue. It’s a demand issue.”
That’s why we feel like we’re in a good place to say — we’ve been saying all along — you really should test the nursing homes. I mean, that was in our guidance over a month ago. If you look back on it, it said: We encourage state and local leaders to focus on testing in nursing homes. That’s been there for a long time.
I think it’s more reissuing and continuing to focus more on nursing homes — as you said — as we’re learning more and more about the devastating impact that has had on nursing homes.
On the early results of coronavirus-focused inspections, and the differences between facilities with and without major outbreaks:
That’s one of the things that’s been really helpful about the CDC/CMS process, in terms of what we’re seeing in the nursing homes. I’ll highlight a few things that we saw. I want to go back to, actually, the situation in Seattle, because I think that was the first one.
In that case, there were some issues around backup, about not having the appropriate staffing in place. There was not a physician that was available, and so as patients were having problems, as they were deteriorating, they didn’t have the appropriate backup in place.
That’s actually one of the reasons why we have changed the regulations around telehealth and nursing homes. They used to have a restriction of just once a month, and we’ve now given them some more flexibility around telehealth — and you can see that states are already taking advantage of that.
The other area that we’ve seen are problems on cohorting and isolation. Some facilities … were built a long time ago. You’ve got four people, maybe, in a room, or two-and-two — but they’re sharing a bathroom. So that ability to cohort, the ability to isolate is very difficult.
The other issue that we’ve seen on the ground are problems around hand hygiene, and just not enough washing — or just even simple things, and not having those hand sanitizer dispensers available.
I think those have been probably the major groups of problems, and that’s one of the things that we did this week on the call with states. We actually brought in the CDC epidemiologist, and had them kind of go through some of the issues, and these are the things that they identified.
On current federal data regarding total numbers of cases and deaths:
We actually did formal rulemaking that’s going to require the nursing homes to report directly into the CDC. Previous to our changes, the requirement was that they report to the local health department, so states actually have this information — and I think, some of you have seen, that states are releasing that data.
The issue is that we haven’t had that data. There’s been issues on the federal level to really understand the extent of it in nursing homes, and so that’s why we’ve made these changes.
Nursing homes are starting to report in. They’re supposed to report the first batch of data by this week. We had to actually go through formal rulemaking; we put out some guidance, letting them know that it was coming. We actually had to create a brand-new data system, and the credit for that goes to the CDC, because they put that together in very short order. Then we had to go through formal rulemaking.
The data should be delivered this weekend — and then, of course, we’ll be going through that data, scrubbing it, making sure that it’s clean, and it’s our intent to get that data out by the end of the month. At that point, we’ll have a much clearer picture of which nursing homes, where, and the extent of the spread of the virus — so not only positive cases, deaths as well, as well as the nursing home staff.
On when nursing homes may reopen to visitors, and whether CMS has any plans to replace some key functions of visitors — such as monitoring for abuse and neglect:
When I say it’s had a devastating impact on nursing homes, I think it’s not just about the number of people that have died — and that is certainly a tragedy in and of itself. But I do think that it’s had a significant impact on families and nursing home residents.
I mean, when people put their loved ones in a nursing home, they obviously want to make sure that they can continue to have contact. They want to make sure that individual is safe, and that they have the best quality of life, and I think because of the coronavirus, all of those things have been significantly impacted.
We’ve seen some nursing homes across the country do great, innovative things in terms of using Skype and bringing in iPads, and really appreciate that staff that’s almost serving as family members. But agree with you that that visitation is so important to quality of life. It’s important not only for the residents — they really appreciate having those visitors — but even for family members, that’s critical for them.
So those are the things that we are looking at as the country’s starting to reopen. We want to make sure that whatever we do, that we are putting the health and safety of the nursing home residents at the top; that’s the most important priority. We’re starting to have those discussions about how we can make sure that nursing homes are safe, and that visitors can come back in a safe way — and what is the appropriate environment for that? What has to be going on in the community?
You’ve heard about our phased approach in terms of reopening — and how do nursing homes fit into that? Those are the discussions that we’re having right now, and that’s the guidance that we intend to put out.
On potential benchmarks for lifting the nursing home visitation ban:
I’m going to save that; we’re working on that right now. I think we’ll be more than happy to share that information with you.
But I’ll just give you at a high level: We have to first understand what’s going on in the community, right? So understanding where the community is in the phases, that’s an important thing. The second thing is what’s happened in the nursing home. Is it safe for that nursing home? Have they done the appropriate testing? Do they know the statuses of their staff, and of the nursing home residents? And what’s happened in that nursing home? Have they had significant spread?
Those are things that we’re all thinking about, and then that’s going to be the basis of how the guidelines are fashioned around addressing those issues.
On Vice President Pence’s recommendation for universal nursing home testing:
I think on the call with the vice president, [it was] sort of a call to action. You’ll see more from CMS on this issue.
On the presentation of the CDC and CMS COVID-19 data:
We want to do two things with the data. Obviously, we want to make sure it’s scrubbed and it’s cleaned. We have to get the data from CDC. We want to do our own analysis, as well, to put out some broad parameters of what we’re seeing, so that that’s easy and digestible. Then, ultimately, it will go on Nursing Home Compare, so that people can look up the specific nursing home and have the report on what happened.
We want to get the information out as quickly as possible. We also want to make sure that people can read it; we’re going to refine it as time goes on. But it will be on Nursing Home Compare.
The other thing that I want to emphasize is that that sort of global information, nursing home by nursing home — families right now have that information. We changed our regulations weeks ago; we put out guidance first, and then we actually went through formal rulemaking. But families have that information.
This is a long-standing requirement, that you have to tell family members that there’s a change in patient status. That’s been going on long-term. What was new was to say: “There is coronavirus in the nursing home.” And we changed those regulations weeks ago. So that’s already out there.
I think we’ve heard a lot from some legislators on the Hill that have said: “Why aren’t you putting this information out there?” And I want to be very clear with you that families have that information today, and they’ve had it for weeks. We’ve heard from family members across the country that said: “It’s great. I’m getting these phone calls. My mom’s okay, but I know that there’s coronavirus in the nursing home.”
They’ve really appreciated the changes that we’ve made, and that we did them so quickly. So I just want to make sure that people have that distinction — that families have that information. The broader data that we’re going to be putting out is just nursing home by nursing home; it’ll be helpful to all of you, to researchers, for people that are considering going to nursing homes. But patients and families have that information today.